Health inspection·September 3, 2024

42 CFR §483.25: Free of Accident Hazards/Supervision/Devices §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. 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. 22 CCR §72501(e) The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of four sampled residents (Resident 1) when Resident 1 fell from the mechanical lift device (also known as Hoyer lift, a device that helps caregivers lift and transfer residents from one place to another) while being transferred by Certified Nursing Assistant (CNA) 1 from his bed to a recliner. This failure resulted in Resident 1 sustaining a head trauma (injury that occurs when there is a direct or indirect blow to the head), which led to hospitalization and subsequent death. FINDINGS Review of the facility's investigative report, dated 4/22/24, indicated "On Friday, April 12, 2024, at approximately 9:59 AM. (Name of Resident 1) under the care of a temporary agency (also known as registry - temporary staffing agency) Certified Nursing Assistant (CNA) during a morning shift, suffered a fall while being transferred using a Hoyer lift ... We originally reported that the fall was caused by the incorrect use of the sling as well as the time of the patient's manner of jerking. However, after interviewing the staff working that day, it was discovered that these statements were only based on speculation. It was incorrectly reported that the patient started jerking while on the floor. However, the investigation clarified that the patient (Resident 1) started jerking while still in the sling during the transfer. The sudden movement caused the patient to slide from the sling and the incident happened so fast that they were unable to prevent the fall ..." Review of Resident 1's "Admission Record," indicated Resident 1 was admitted on 2/4/12. Review of Resident 1's physician's "Progress Note," dated 3/14/24, indicated Resident 1 had diagnoses including severe Lewy body dementia (a disease associated with abnormal deposits of protein in the brain that can lead to problems with thinking, movement, behavior, and mood) and unspecified secondary parkinsonism (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of Resident 1's MDS (minimum data set - a standardized assessment tool for nursing home residents), dated 1/15/24, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was dependent on two or more staff to transfer from bed to chair and vice-versa. Review of Resident 1's "Post Fall Assessment (PFA)," dated 4/12/24, indicated, "Patient (Resident 1) fell on the floor while on Hoyer lift while being transferred from bed to recliner." The PFA indicated Resident 1 fell on 4/12/24, at 9:59 AM. Review of Resident 1's "Resident Transfer Record," dated 4/12/24, indicated Resident 1 was transferred to a general acute care hospital (GACH) on 4/12/24, for fall sustained injuries. Review of Resident 1's "Discharge Summary" from the GACH Emergency Department (ED), dated 4/16/24 at 4:53 PM, indicated Resident 1 was brought in by ambulance after a fall from a Hoyer lift at a SNF (skilled nursing facility) with a head strike (head injury) that caused a severe traumatic intracranial hemorrhage (any bleeding within the brain) with herniation (occurs when pressure within the skull is increased, causing the brain tissues to move from one part of the brain to another adjacent part of the brain). Further review of the Resident 1's Discharge Summary indicated, "Neurosurgery (medical specialty concerned with the diagnosis and treatment of patients [residents] with injury and diseases of the brain and the spine) determined unsurvivable injury (from which survival is difficult or impossible) without intervention and even with surgical intervention, high likelihood to be unsurvivable..." The Discharge Summary also indicated Resident 1 was placed in comfort care (medical care designed not to cure, but to reduce a patient's pain and keep him or her comfortable) "...then died in the ED as a result of head trauma related to a fall at SNF." During an interview on 4/15/24, at 10:29 AM, the Director of Staff Development (DSD) stated CNA 1 was assigned to Resident 1 during the AM shift (7:00 AM to 3:30 PM work shift) on 4/12/24. The DSD also stated, "CNA 1 is from registry. We haven't trained CNA 1 in using the Hoyer lift. We assumed that she was trained and know the policy and procedure since she was hired by a registry agency." During a concurrent observation and interview on 4/15/24 at 1:22 PM with CNA 2, a sling labeled "BHM Medical Inc [incorporated] (manufacturer of the sling)" and a mechanical lift device labeled, "Invacare Reliant 450 (IR 450)" were stored in the clean equipment area. CNA 2 stated, "We use this type of Hoyer lift and sling for everyone that needs it." During an interview on 4/16/24, at 10:51 AM, with Housekeeping Staff (HS) and CNA 3, HS stated that on 4/12/24, she was in the hallway when CNA 3 asked her to go to Resident 1's room to help CNA 1. HS stated when she entered the room, Resident 1 was lying down in bed with the sling on, and CNA 1 was preparing to transfer Resident 1 using the IR 450. HS further stated that while CNA 1 was lifting Resident 1 using the IR 450, Resident 1 started shaking and sliding off the sling. HS added, "The CNA (referring to CNA 1) started to grab a chair. It happened so fast, (Resident 1) slide [sic] down butt first." During a telephone interview on 4/17/24, at 1:15 PM, CNA 1 stated, "I worked night shift before in the facility on 3/6/24 from 11:00 PM to 7:30 AM. I worked day shift for the facility for the second time on 4/12/24 from 7:00 AM to 3:30 PM." CNA 1 stated, "On 4/12/24, I checked in during the morning shift (7:00 AM to 3:30 PM), and I was given my assignment by the Charge Nurse from the night shift." CNA 1 also stated, "When I transferred (name of Resident 1), the size of the sling that I used was a half sling (referring to BHM hygienic sling [a type of sling that supports the patient during the toileting process to provide safe and comfortable transfers]). CNA 1 stated the half sling she used on Resident 1 during mechanical lift transfer on 4/12/24 was the "green loop... That sling is for bigger people." CNA 1 stated, "I had never gotten an orientation from the facility on how to use the exact Hoyer lift, also the sling." During an interview on 4/17/24, at 2:42 PM, CNA 4 stated Resident 1's arms have contractures (a fixed tightening of muscle, tendons, ligaments, or skin). CNA 4 also stated, "When you try to move his hands away, he normally jerks," and Resident 1 typically has jerking movements when he is placed in the Hoyer lift. During an interview on 4/17/24, at 3:12 PM, CNA 5 stated after Resident 1's fall, CNA 1 asked her assistance with transferring another resident (Resident 2) using a Hoyer lift from the wheelchair to bed. CNA 5 stated upon entering Resident 2's room, she saw the half sling placed on the bed in preparation to put it behind Resident 2 before the transfer. CNA 5 stated she observed that the half sling was improperly positioned on its opposite side by CNA 1. CNA 5 stated, "I noticed right away that the sling was not properly set up; she (CNA 1) had put it in the other way. So, I showed her how it should have been done." CNA 5 stated if the sling was placed incorrectly behind the resident, the belt of the half sling would not be able to secure the resident during transfer and had the risk of falling. During an interview on 4/18/24, at 11:32 AM, Licensed Vocational Nurse stated Resident 1 does not talk but he grunts, has contractures, and when staff try to move his hands, he jerks. During an interview on 4/19/24, at 1:45 PM, the DSD stated Resident 1 did not have a physician's order for the type and size of sling to use during transfers. The DSD also stated the size of sling to use on a specific resident is determined by the height and weight of the resident. The DSD confirmed there was no documentation in Resident 1's medical record that Resident 1's height and weight were used to determine the type and size of sling to use during transfers. During an interview on 4/19/24, at 2:14 PM, the DSD stated, "If a resident is given a sling that is too large to use for a Hoyer lift transfer, it is a risk of falling out of the sling. If it's too small, it is a risk for skin issue." During an interview on 4/19/24, at 2:32 PM, CNA 4 was asked what size of sling Resident 1 normally used prior to the fall incident on 4/12/24. CNA 4 stated, "(Name of Resident 1) was using the medium sling. Yellow." During a concurrent interview and record review on 5/8/24, at 11:01 AM with the DSD and the Director of Nursing (DON), the facility-provided document, titled "BHM Medical Inc Voyager Series 420 Plus Part Number 9100001, Ceiling Lift System (BHM User Manual)," dated July 2002, was reviewed. The BHM User Manual indicated, "Every patient has different needs. It is important to choose the right sling based on the needs of the patient to be transferred as well as their physical ability and size...User instructions for: Hygienic Sling - The sling is excellent for changing incontinence pads or to transfer onto a toilet as it provides an open area from the middle of the back to the middle of the thigh. In order to use this sling, the patient must have a good muscle tone in their shoulders and upper body." Further review of the BHM User Manual indicated hygienic slings come in various sizes, each sling is color-coded to correspond with different chest sizes (measurement): red for small (residents with chest size ranging from 68 to 89 centimeters [cm]), yellow for medium (chest size 89 to 107 cm), and green for large (chest size 107 to 125 cm). The DSD was asked if Resident 1's chest was measured. The DSD stated, "No." The DSD further stated that when Resident 1 fell, he was in a hygienic sling (half sling) and Resident 1's sling size should be medium, and the color code is yellow. During an interview on 5/8/24, at 11:10 AM with the DSD and the DON, the DSD stated, "Only Invacare Sling should be used in Invacare Reliant 450. Invacare to Invacare ... for (resident) safety." During a concurrent interview and record review on 5/8/24, at 11:31 AM, with the DSD and the DON, the undated facility's P&P, titled "Lift Program: Policy and Guide (LPPG)" was reviewed. The LPPG indicated "...2. Policy: All resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's Care Plan...3. Procedures: A. Compliance: All personnel are responsible for implementing this policy... B. Resident Handling and Movement Requirements:...2. Lifting equipment and other resident assist devices will be operated in accordance with instructions and training... Preferred Methods for Lifting and Transferring...Total Dependent Residents... All residents classified as total dependence...should be lifted and transferred between beds, chairs...by means of a full-sling mechanical lift device..." The DON stated, "They (staff) should use the full sling (for Resident 1)." The DON further stated, "There's no strength (referring to Resident 1's upper body), he needs total assistance, (Resident 1) cannot move his body. Full sling should be used (for Resident 1) for safety, (full sling) provides total body lift on the patient." The DON stated total assistance means the resident is totally dependent on staff to perform an activity. Review of Resident 1's care plan titled "Activities of Daily Living (ADL)," last updated on 2/14/23, indicated Resident 1 needed assistance with transfer related to dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination.) The ADL care plan did not address how Resident 1 will be transferred from bed to chair and vice-versa. Review of Resident 1's care plan titled "Mechanical Lift (ML)," last updated on 2/14/23, indicated Resident 1 will be transferred safely at all times from bed to wheelchair via mechanical lift. Further review of the ML care plan indicated interventions that include "two staff will assist with mechanical lift transfers ... prior to transfer, make sure resident is not restless or agitated." The ML care plan did not indicate the type and size of sling to be used for Resident 1 during transfers. During a concurrent interview and record review on 5/8/24, at 11:40 AM with the DON, Resident 1's care plan titled, "Fall Risk Prevention and Management (FRPM)," last updated on 2/14/24 was reviewed. The FRPM care plan indicated Resident 1 was at risk for fall related to lack of awareness, cognitive deficit (problems with a person's ability to think, learn, remember, use judgement, and make decisions), communication deficit, and needed total care. The FRPM care plan also indicated Resident 1 has diagnoses of dementia and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). The DON verified Resident 1's care plan did not indicate the type and size of the sling to be used during mechanical lift transfers, which should be specified "for safety" and further stated the care plan was "not personalized" for Resident 1. The DON also stated it is important for Resident 1's care plan to be person-centered (means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices) so as to provide "proper care of the patient (Resident 1), serves as guidance for nurses, (to) know the needs of the resident." The DON also stated if the care plans were not person-centered, "if the nurse is new, it will mislead the nurse on what to do with the resident." During a concurrent interview and record review on 5/8/24, at 11:42 AM with the DSD and the DON, the facility policy, titled "Policy on Hiring Temporary [Registry] Staff (PHTS)," dated 10/2/23, was reviewed. The PHTS indicated, "The temporary employee should arrive 1 (one) hour before the start of shift to be properly orientated and briefed regarding their respective assignment...The department supervisor (charge nurse) will be responsible for orientating the temporary employee of their assignment (facility, emergency procedures, resident assignment, etc.)." The DSD stated, "We were not giving orientation (to temporary staff), it was given that they had orientation (from the registry agency)." The DON stated, "I thought the agency staff (CNA 1) has an experience with the use of Hoyer lift." The DON further stated, "They should be," when asked if temporary staff should be given orientation on the use of the facility's mechanical lift devices and the type and size of slings specific for each resident prior to providing care. During a concurrent telephone interview and record review on 5/8/24, at 1:46 PM with Customer Success Rehab (CSR, responsible for providing customer service, and resolving customer issues for Invacare Corporation), the CSR emailed the "Invacare® Reliant (Trademark) 450/600 User Manual (IRUM)," dated 2022. The IRUM was reviewed with the CSR. The IRUM indicated, "...2. Safety - The Safety section contains important information for the safe operation and use of this product ...2.2 Operating Information. 2.2.1 General ...Warning!... Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. S