Health inspection·January 24, 2024

The following reflects the findings of the California Department of Public Health during the investigation of one facility reported incident. Facility reported incident number 867308. Representing the Department was Surveyor 47596. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Class A State Citation number 230019616 was written at 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. On 11/8/2023, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a fall with significant injury. The facility failed to ensure the plan of care for a safe transfer was implemented for one of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) l and Nursing Assistant (NA) 2 did not use a Hoyer lift (a mechanical device for lifting and transferring immobile patients) and assisted Resident 1 to a standing position. Resident 1 was unable to stand and was lowered to the floor. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. Findings: A review of Resident 1's Admission Record indicated she was admitted to the facility on 5/16/2022, with diagnoses that included displaced trimalleolar fracture of right lower leg (a fracture of the bones of the ankle), morbid (severe) obesity (severely overweight) and difficulty walking. A record review of Resident l's Minimum Data Set (MDS, a process for clinical assessment of all residents of nursing homes) dated 9/26/2023 Functional Status indicated Resident 1 required assistance and support to transfer to or from bed, chair, wheelchair or standing position. For balance during transitions and walking, Resident 1 was noted as not steady, only able to stabilize with staff assistance. Resident l's Fall Risk Assessment score was 13 (greater than 13 is high risk for falls). A record review of Resident 1's Lift/ Transfer Evaluation dated 8/18/2023 indicated the resident could not bear weight and her current weight was over 200 pounds. During record review of Physical Therapy Treatment Encounter Note dated 10/25/2023 indicated Resident 1 required substantial/maximal assistance for transfers. Resident 1 's Functional Skills Assessment Mobility Performance Score was 2 (ranges from 0-12 ,12 indicating a higher functional ability) It indicated Resident 1 was a fall risk with right lower leg pain. During a record review of Resident 1's fall care plan dated 10/26/2023, indicated she was at risk for falls with a past history of fall with ankle fracture prior to admission and required use of a Hoyer lift for transfers with assist of 2. During a record review of Interdisciplinary Team (IDT, a meeting between department heads to discuss/plan care) Progress note dated 10/26/2023, indicate at 2:50 PM CNA 1 went to the nurse's station during change of shift to report that Resident 1 was on the floor. CNA 1 reported that Resident 1 was supposed to have her shower and CNA 1 and NA 2 were trying to remove her brief prior to shower. CNA 1 claimed that Resident 1 offered to stand up so they can remove her brief easily and CNA 1 assisted her to stand up. Resident 1 was unable to support her weight and was very unsteady, so CNA 1 assisted Resident 1 to slide down to the floor. Resident l's right knee gave out and it hit the floor and she was then complaining of right knee pain. The Nurse Practitioner was notified and an order for x-ray was received. Resident 1 and family refused x-ray and requested to be sent out to acute care hospital. Resident 1 was transported by ambulance at 4:15 PM to acute care hospital and was found to have subtle, nondisplaced mildly impacted fractures of the proximal tibia, fibula neck and proximal fibular neck and proximal fibular shaft (fracturs of both bones of the right knee). A soft cast was applied, and resident returned to facility at approximately 8:10 PM. During record review of Resident 1's Pain Interview dated 9/26/2023 it indicated Resident 1 had pain in the previous 5 days, pain was occasional, had no effect on sleeping, did not limit Resident 1's day-to-day activities and pain scale rating was 4/10 (0 being no pain and 10 being the worst pain). During a review of Resident 1's Medication Administration Record dated 10/1/2023 through 11/30/2023 it indicated Resident 1 was taking Hysingla ER (a extended release opiate medication used to treat chronic pain) once daily. After the fall on 10/25/2023 Resident 1 was taking Norco 5-325 (a mixture of narcotic pain medication and Tylenol used to treat severe pain) for 13 days averaging 3 pills per day with an average pain scale of 8 (severe pain). Resident 1 also took Tramadol (a narcotic pain medication) on 4 days during that time with an average pain scale of 8. A review of Resident 1's Nurse's Note, dated 10/28/23 at 4:45 am, indicated that Resident 1 was asking why her pain medication was not brought to her on time. The nurse explained that the medication is ordered as needed for pain and not a routine schedule. The nurse further explained that if Resident 1 was asleep, the nurse would not wake Resident 1 to take her pain medication. Resident 1 refused incontinent care twice, because she needed four people to help turn her. A review of In-Service Mechanical Lift/Transfer Equipment lesson plan dated 10/25/23 taught by Director of Staff Development (DSD) and Director of Physical Therapy (DPT) indicated that the best safety controls are machines, equipment and devices that do the lifting and transferring for you including gait belts and electric lifts (Hoyer lifts are electric devices that lift and transfer a resident in a sling). A resident's physical needs and abilities must be constantly checked to ensure that the safest lifting techniques are being used. Before transferring a resident, check the Kardex, care plan, care card or assignment sheet. Factors that should be considered: the individual's required level of assistance, the resident's weight and height, the person's cognitive status and physical ability. You should always try to avoid physically lifting residents. Always follow your facility's policies for lifting. NA 1 attended this in-service. CNA l did not attend this in-service. A review of Module 5 of Nursing Assistant Certification lesson plan dated 2019, completed by CNA 1 and NA 1 indicated mechanical lift devices should be used for residents who are morbidly obese, have fragile skin or are unable to bear weight. A review of Medical Doctor orders dated 10/3l /2023 indicated an order for Hoyer transfer per therapy department every shift. During an interview on 11/9/2023 at 7:57 AM, with Resident 1 in her room she recounted the circumstances at the time of the fall on 10/25/2023. Resident 1 stated at approximately 2:50 PM, she had been transferred from her wheelchair to her shower chair via mechanical lift by CNA 1 and NA 2. Resident 1 stated once in the shower chair it was noticed that she still had on her brief. CNA 1 stated she would lift Resident 1 while NA 1 pulled down her incontinence brief. Resident 1 stated she said "no", but CNA I lifted her up under her arms but couldn't support her weight, so Resident 1 "slithered" to the floor. Resident I landed most of her weight on her right knee with immediate pain. Resident l laid on the floor while they called for help. LVN 1 (Licensed Vocational Nurse) and Registered Nurse (RN) 1 arrived quickly and assisted her into the mechanical lift sling and was put back in bed. Resident 1 texted her son, who works at the local hospital, and told him what happened. Resident 1 and her son agreed she should be taken by ambulance to the hospital where he would be waiting for her. She returned to the facility that evening with a soft cast on her right leg with a diagnosis of right medial tibial fracture (a break of the lower leg bone). She was taking Norco (a narcotic pain medication) for the first 12 days after the fall, but the medication made her "loopy". Resident l's pain medication was changed to Tramadol (a pain medication) and Tylenol (an over-the-counter pain medication). Resident 1 reports that before her fall she was able to stand for 15 seconds during her Physical Therapy (PT) session earlier in the day of her fall. Resident 1 is now having PT in her room in her bed and only on her upper body. On 11/8/2023 at 2:45 PM during interview with Director of Physical Therapy/Director of Rehab (DPT/DOR) stated that on 10/25/2023 Resident 1 was assessed as "dependent assist" which means she requires a Hoyer lift for transfers. When asked how CNAs know what level of assistance a resident requires, DPT/DOT stated that when a resident's status changes, physical therapy (PT) in services the CNAs. When asked if they in-service all CNAs on all shifts, DPT/DOR said no, the CNAs find out from the nurses. DPT/DOR stated that Resident 1's status hasn't changed in a long time. During record review of Emergency Department provider notes dated 10/25/2023 at 4:40 PM indicated the patient (Resident 1) had a fall while transferring at the care home. Patient is non-weight bearing (not allowed to put any weight) and staff allowed her to stand where she collapsed. She was getting physical therapy and had been bed bound for 18 months. Patient reported 10/10 on a pain scale (severe worst pain) to right knee. A review of Xray results indicated Resident I was diagnosed with a right subtle, nondisplaced mildly impacted fractures of the proximal tibia and subtle nondisplaced fractures of the proximal fibular neck and proximal fibula shaft and severe osteopenia (a fracture of the bones of the knee and a loss of bone strength). A soft cast was applied to right leg and Resident 1 was discharged via ambulance back to the facility at approximately 8:20 PM. On 11/9/2023 at 4:30 PM during telephone call with CNA 1 she recounted that on 10/25/23 at approximately 2:50 PM she was getting Resident 1 ready to shower. She and NA 2 had already used the Hoyer lift to transfer Resident 1 from her wheelchair to her shower chair. Resident 1 offered to stand up so her brief could be removed. CNA 1 assisted Resident 1 to stand but Resident 1's legs gave out and CNA 1 was unable to support her weight. CNA 1 assisted Resident 1 slowly to the floor where Resident 1 hit her knee, CNA 1 immediately went to the nurse's station to get help leaving NA 2 with Resident 1. When asked how CNAs find out a resident's transfer status, she stated CNAs must ask other CNAs or the nurses. She admitted she should have used the Hoyer lift but Resident 1 stated she could stand. In violation of the above cited standard, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to CNA l and NA 2 did not use a Hoyer lift and assisted Resident 1 to a standing position. Resident 1 was unable to stand and was lowered to the floor, resulting in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. This violation presented a substantial probability that death or serious physical harm would result.