Other·September 21, 2023

Facility: Asistencia Villa Rehabilitation and Care Center Recertification Event ID # 8XQ511 Representing the California Department of Public Health: HFEN 44529 Citation “B” Regulation Violation T22 § 72637. General Maintenance. (a) The facility, including the grounds, shall be always maintained in a clean and sanitary condition and in good repair to ensure safety and well-being of patients, staff, and visitors. (c) All buildings, fixtures, equipment, and spaces shall be maintained in operable condition. (d) Personnel shall be employed to provide preventive maintenance and carry out the required maintenance program. The facility failed to ensure all mobility equipment are safe to be used on patients during transfers. An electric lift used by two Certified Nursing Assistants (CNA 1 and 2) to transfer a patient (Patient 8) had a base that did not securely lock into place, causing the lift to tilt and the digital scale hit Patient 8 ‘s forehead. This failure resulted in Patient 8 sustaining two abrasions (the surface layers of the skin has been broken) on the right side of the forehead. On August 11, 2023, at 10:46 AM, during an annual recertification survey, a complaint investigation was conducted to investigate injuries sustained when an electric lift malfunctioned. A review of Patient 8’s “Face Sheet “ (a document containing basic information), dated August 9, 2023, indicated Patient 8 was admitted to the facility on March 2, 2022, with diagnoses that included morbid obesity (having too much body fat), other symptoms and signs involving the nervous (includes the brain, spinal cord, and a complex network of nerves) and musculoskeletal (includes the bones and muscles) system. A review of Patient 8’s “MDS (Minimum Data Set – a standardized assessment tool that measures health status in nursing home patients) Section C (Cognitive [involving conscious intellectual activity] Patterns),” dated June 1, 2023, the “MDS Section C” indicated, Patient 8 had a BIMS (Brief Interview for Mental Status- a tool used to screen how a patient is functioning cognitively) score of 12 (a BIMS score of 8 to 12 suggests moderately impaired cognition). During a review of Patient 8’s “MDS Section G (Functional Status),” dated June 1, 2023, the “MDS Section G” indicated, Patient 8 was totally dependent for transfers to and from bed, requiring two-person physical assist. An interview on August 11, 2023, at 10:46 AM with Patient 8, she stated she CNA 1 and CNA 2 were transferring her from bed to the chair using an electric lift. The electric lift that did not lock, causing it to tilt and hit her on the forehead. An interview on August 11, 2023, at 10:55 AM with CNA 1, she stated, she was transferring Patient 8 from bed to chair using an electric lift with CNA 2, when the two legs of the lift did not lock and collapsed closer together, causing the electric lift to tilt over and the weight scale attached to the lift hit Patient 8 on the right side of the forehead. An interview on August 11, 2023, at 11:52 AM with CNA 2, she stated they were transferring Patient 8 from bed to chair when the legs of the electric lift closed and caused the lift to tilt and part of the weighing scale hit Patient 8 on the right forehead. CNA 2 stated she noticed redness on Patient 8’s the right forehead and reported the incident to the Charge Nurse. An observation on August 11, 2023, at 12:00 PM in hallway 200, CNA 1 and CNA 2 identified the electric lift that was used for Patient 8. The electric lift had a sticker label that indicated, “Brand name and model,” with “#1” (number one) handwritten on the boom (a beam used to move and carry the load) and mast (the vertical bar that fits into the base). A concurrent observation and interview on August 11, 2023, at 12:05 PM with the Maintenance Supervisor (MS), the MS demonstrated the use and operation of electric lift number one. The MS stated the legs of the base will spread wide and open by using the shifter handle located behind the mast of the lift. The MS further stated the lift should only be used to lift patients with the legs in maximum open position and locked in place. The MS was unable to demonstrate the legs of the base were able to lock securely in place during use. A concurrent interview and record review on August 11, 2023, at 2:00 PM with the MS, the electric lift number one’s Operations Manual (OM) for “Brand name and model”, titled, “Manual/Electric Portable Patient Lift Owner’s Installation and Operating Instructions”, undated, was reviewed. The OM indicated, “… Operation… Warning… Only operate this lift with the legs in maximum open position and locked in place. The base legs must be always locked in the open position for stability and patient safety when lifting and transferring a patient…” The MS stated the electric lift number one did not lock securely into place when in an open position during use for patient transfer. The MS further stated the OM’s instruction for safe transfer of patients using the lift was not followed. A concurrent interview and record review on August 11, 2023, at 2:10 PM with the Director of Rehabilitation (DOR), Patient 8’s medical record document titled, “PT (Physical Therapy) Evaluation and Plan of Treatment (PT evaluation),” dated with “Certification Period 4/29/2023 – 5/25/2023” was reviewed. The “PT evaluation” indicated, “…Functional Mobility Assessment… Transfers= Total Dependence w/o (without) attempts to initiate (Pt [patient] is [brand of lift] dep [dependent]…).” The DOR stated Patient 8 required two-person assist during transfers with the use of a lift. A concurrent interview and record review on August 11, 2023, at 2:15 PM with the Registered Nurse Supervisor 1 (RN 1), Patient 8’s “Progress Notes,” dated July 18, 2023, was reviewed. The “Progress Notes” indicated, a late entry for July 17, 2023. The “Progress Notes” further indicated, “… while being transferred from bed to w/c (wheelchair) using (brand of lift) lift with two CNAs the (brand of lift) lift bumped her R (right) side of the face d/t (due to) (faulty) equipment… Patient was assessed with 2 small scrapes to the right side of the face…” The RN 1 stated the lift used for Patient 8 had legs at the base that did not lock and tipped over, hitting Patient 8 on the right side of the forehead, causing two scrapes measuring two centimeters each that required first aid. A concurrent interview and record review on August 11, 2023, at 2:26 PM with the Administrator, the facility’s policy, and procedure (P&P) titled, “Lifting Machine, Using a Mechanical,” revised July 2017 was reviewed. The P&P indicated, “… The purpose of this procedure is to establish the general principles of safe lifting using mechanical lifting device. It is not a substitute for manufacturer’s training or instructions… Steps in the Procedure… 7. Make sure the lift is stable and locked… 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition…” The Administrator stated the electric lift should have been in good repair and safe for patient use. The Administrator further stated both the P&P and operations manual for using the electric lift were not followed. Conclusion: In violation of the above standard, the facility failed to: Ensure all mobility equipment are safe to be use on patients during transfers, in good repair, maintained in operable condition and preventive maintenance carried out according to the manufacturer’s recommendation and facility’s policy and procedure. This violation had a direct or immediate relationship to the health, safety, or security of the patient.