Health inspection·October 6, 2022

REGULATION VIOLATION: Title 42 of the Federal Code of Regulations §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. California Code of Regulations, title 22, § 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. On August 11, 2022, at 2:30PM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient A's fall with injury while using the mechanical lift to perform the weighing. On August 9, 2022, at 8:30PM, Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) used the sling scale lift (SSL) to weigh Patient A. During the process of lifting, both LVN 1 and CNA 1 heard a snap, then the leg strap disconnected, and Patient A fell on the floor. The facility failed to: a. Follow its Policy and Procedure (P&P) for safe patient handling and mobility, which resulted in Patient A's falling, sustaining a laceration (a deep cut or tear in the skin) on the back of her head. Patient A received staples to the back of her head and was required to be transferred to the general acute care hospital (GACH). Patient A was subsequently admitted to the intensive care unit (ICU) for a higher level of care. b. Follow manufacturer's instructions guide for safe lifting technique during a sling scale lift (SSL- a mechanical device used to assist residents and staff during transfers) to not to lock the SSL during lifting the patient. Patient A, a 50-year-old female, was admitted to the facility on July 22, 2022, with diagnoses of chronic respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), pseudomonas pneumonia (a type of germ causes inflammation of the lungs), encephalopathy (diffuse disease of the brain that alters brain function or structure), and hypertension (high blood pressure). Patient A had inability to perform activities of daily living independently and needed total assistance with bed mobility, transfer, toileting, ambulation, and personal hygiene. A review of Patient A's clinical record, "Fall Risk" (Facility's) dated August 1, 2022, it indicated, "Fall Risk Scale Type, John Hopkins" and "Fall Risk Score 6... moderate risk (a tool used to facilitate early detection of risk of fall for adult patients, a score of 6 is considered moderate risk)," A review of Patient A's facility's clinical record, "Change of Condition" (COC), dated August 9, 2022, it indicated, "Patient fell on the floor during weighing when the scale leg strap was accidentally disconnected from the patient. Patient landed on her buttocks then her head. MET [medical emergency team] was called due to bleeding noted on the back of Patient's head... " A review of Patient A's clinical record, "RRT Activation and Response- Text," (RRT­ Rapid Response Team) dated August 9, 2022, it indicated, "... Team called for accidental fall. Upon arrival patient was found in supine [(lying face upward)] position on floor, bleeding noted on floor from back of head... " and "Outcome: Transferred to ICU. Follow up: MD 1 placed 5 staples to scalp laceration." A review of Patient A's clinical record, "History and Physical" (H&P from GACH), dated August 9, 2022, indicated, "Patient fell and suffered injury to the back of her head and patient started to bleed from the scalp, Patient has hematoma (bleeding usually caused by an injury) and scalp was stapled, blood pressure dropped..." During an observation on August 11, 2022, at 3:40 PM, Patient A was observed at GACH in the ICU bed. Patient A was awake, nonverbal, unable to follow commands, and was observed to have staples on the back of her head. During an interview on August 11, 2022, at 2:45 PM, with the Clinical Director (CD), the CD stated, LVN 1 and CNA 1 used the [Name of lift equipment company] lift equipment to weigh Patient A. A sling was used and in the process of lifting, both stated they heard a snap, then the leg strap disconnected, and Patient A fell on the floor. During a concurrent observation and interview on August 11., 2022, at 2:55 PM, in the maintenance room with the Clinical Manager (CM) and the CD, both acknowledged, the lift equipment present in the room was the lift equipment used to lift Patient A. During an interview on August 11, 2022., at 3:05 PM, with the Director of Staff Development (DSD), the DSD stated "All staff are trained on proper use of the lift equipment." The DSD further stated all new employees are provided orientation and yearly training with the lift equipment. Staff are trained and are validated with successful return demonstration. A review of the facility's record, "[Name of the lift equipment company] Demonstration Checklist," undated, indicated the equipment "Slowly lifts the patient so that the patient is off the bed surface (does not lock wheels when lifting)." A review of the facility's record, "[Name of lift equipment company] Instruction Guide," undated, indicated "Operation... Locked wheels during lifting increases the risk of the lift tilting over." During a concurrent phone interview and record review on August 17, 2022, at 3:40PM, with the CM, the facility's record, "[Name of lift equipment company] Instruction Guide," undated, was reviewed. The Instruction Guide indicated, "... during lifting, wheels should remain unlocked so that the lift may shift to the patient's center of gravity." The CM stated, "If wheels are locked during the process of lifting, manufacturer's instructions are not being followed." The CM further stated, "Staff are trained to use that equipment and are expected to follow the policy for safe lifting techniques." During a phone interview on August 11, 2022, at 10:05PM, with LVN 1, LVN 1 stated she was called in the room to assist CNA 1 to weigh Patient A. The lift equipment was used to weigh Patient A and while lifting the patient they heard a snap, the sling came unhooked, and Patient A slipped down on the floor. During a follow up phone interview on August 17, 2022, at 2:42 PM with LVN 1, LVN 1 stated she pressed the button to lift Patient A and the lift equipment's wheels were locked. LVN 1 further stated she's getting the training yearly. During a phone interview on August 11, 2022, at 10:35 PM, with CNA 1, CNA 1 stated he heard a snap while lifting Patient A with the lift equipment. CNA 1 further stated the sling came unhooked and Patient A slipped out and landed on her bottom. During a follow up phone interview on August 17, 2022, at 12:06 PM, with CNA 1, CNA 1 stated while lifting Patient A with the SSL, the lift equipment's wheels were locked and that is how he was trained upon hire and orientation. During a phone interview on August 17, 2022, at 2:47 PM with CNA 2, CNA 2 stated when using the lift equipment, the wheels are to be locked when lifting the patient. CNA 2 further stated that is what she remembers during training. During a phone interview on August 17, 2022, at 2:55 PM, with CNA 3, CNA 3 stated when she uses the lift equipment, the wheels are to be locked when lifting the patient, to stop it from moving. A review of the facility's record "Investigation Summary" (IS), dated August 17, 2022, indicated, "Conclusion: ... fall was the result of human error... staff failing to follow the policies and instructions for safe lifting techniques... " A review of the facility's P&P titled, "Safe Patient Handling and Mobility" (SPHM) effective date: December 13, 2017, indicated, "Policy: It is the policy of [NAME] Health that health care workers (HCW) who provide patient care are responsible for working in a safe manner when performing vertical lifts, lateral lifts, repositioning, and management of bariatric patients. Purpose: To establish guidelines for consistent safe patient handling and mobility (SPHM) practices. SPHM: refers to a policy and programs that use people, process and technology that allows caregivers to safely lift and move patients without causing injury and unnecessary physical stress." Conclusion: In violation of the above cited standards, the facility failed to: a. Follow its P&P for safe patient handling and mobility, which resulted in Patient A's falling and sustaining a laceration on the back of her head. Patient A received staples to the back of her head and was required to be transferred to the GACH and subsequently admitted to the ICU for a higher level of care. b. Follow manufacturer's instructions guide for safe lifting technique to not to lock the SSL during lifting the patient. This violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result and is a class B violation.