Other·August 21, 2024

“A” Citation- Patient Care Policies and Procedures Desert Springs Post Acute Complaint: CA00905649 California Code of Regulation, Title 22 section 72523 Patient Care Policies and Procedure 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieve. Code of Federal Regulations, Title 42, 483.25(d)(1)(2) (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 accident. On July 25, 2024, an unannounced visit was made to the facility to investigate a quality care concern. As a result of the investigation, the California Department of Public Health (CDPH) determined that the facility failed to: a. Provide a two person assist for Patient A during transfer from a regular chair to a wheelchair on June 18, 2024. b. Use a gait belt (a thick fabric or vinyl belt that is placed around a patient's waist to help with mobility and prevent falls) to assist Patient A during transfer from a regular chair to wheelchair on June 18, 2024. c. Ensure the wheelchair’s brake was operating properly (wheels will not roll/move when locked) during patient’s transfer to the wheelchair. These failures resulted in a fall which led for the patient to sustain injury to the tibial plateau [flat top part of the shin bone] subsequently causing development of genu valgum [knocked-knee - the knees angle in and touch each other when the legs are straightened] deformity. A review of Patient A’s “ADMISSION RECORD” indicated Patient A was admitted to the facility on June 10, 2024, with diagnoses which included aftercare following joint replacement surgery, morbid [severe] obesity, and osteoarthritis [degenerative joint disease]. A review of Patient A's, "Fall Risk Observation/Assessment," dated June 10, 2024, indicated, "...Score 20...Balance...Evaluate resident's balance while standing, sitting and during transitions...Ambulates with problems and with devices (gait is unsteady, slow, lurching)...Scoring...HIGH RISK 16-42..." The assessment indicated Patient A is high risk for fall. A review of Patient A's progress notes titled, “Alert Charting,” dated June 18, 2024, indicated, "...Certified Nursing Assistant (CNA) reported to the LPN (Licensed Practical [Vocational] Nurse- LVN) that the resident fell during transfer… Per CNA, they were mid-transfer from chair to wheelchair, but the wheelchair rolled back, and the resident fell back, landed onher (sic) buttock and hit her head on the air condition (AC) unit. Wheelchair was locked on both sides, but the wheels were still moving. Per resident she tried to sit back but the chair moved, and she fell on her butt and hit her head on the AC unit and has some pain on the back of her head..." On June 25, 2024, at 11:55 a.m., during interview inside Patient A's room, Patient A stated the (CNA) did not lock the brakes of the wheelchair, so the wheelchair moved during her transfer which led her to fall and hit her head. Patient A stated she was brought to the Emergency Room (a medical department that provides immediate treatment for acute illnesses or injuries) after she fell, for further evaluation. On June 26, 2024, at 10:25 a.m., during an interview, the Physical Therapy Assistant (PTA) stated Patient A reported falling during transfer from a regular chair to wheelchair since the CNA did not use a gait belt and the wheelchair moved during the transfer from chair to wheelchair. The PTA stated the staff should use a gait belt to assist in restoring balance and to prevent the patient from falling. In addition, the PTA stated he knew about the wheelchair not functioning properly before the fall incident and he stated the wheelchair should have been sent to the maintenance services for repair. On June 26, 2024, at 3 p.m., during an interview, CNA 1 stated Patient A asked her for support while standing and when Patient A leaned on the wheelchair, the wheelchair moved causing the patient to lose balance and fall on her buttocks, hitting the back of her head. CNA 1 stated she did not use a gait belt. CNA 1 further stated, she should have stayed behind Patient A’s back to prevent the fall. On June 26, 2024, at 3:45 p.m., during an interview, LVN 1 stated, the CNA was helping transfer the patient (Patient A) by herself, from a regular chair to the wheelchair when the patient lost her balance and fell on her back. LVN 1 stated she checked the wheelchair after the fall and even when the lock was engaged, the wheels were still rolling. LVN 1 stated CNA 1 did not use a gait belt in transferring the patient and did not use two-person assist during transfer, which could have prevented the patient's fall. LVN 1 stated Patient A required two-person support with transfers. On July 5, 2024, at 12:32 p.m., during an interview, the Director of Staff Development (DSD) stated the CNA should be using a gait belt when assisting patient during transfers to ensure safety. The DSD stated CNA 1 should have used a gait belt to assist Patient A during the transfer from a regular chair to a wheelchair. On July 5, 2024, at 12:42 p.m., during an interview, LVN 2 stated CNA 1 was supposed to use a gait belt to transfer Patient A. However, the CNA did not use a gait belt during Patient A’s transfer to the wheelchair which placed Patient A at risk for fall. On July 10, 2024, at 2:46 p.m., during an interview, the Patient Representative (PR; family member) stated Patient A had an appointment with the orthopedic surgeon (a medical doctor who specialized in diagnosing, treating, preventing, and rehabilitating musculoskeletal system disorders such as the bones and joints) on July 10, 2024. The PR stated the orthopedic surgeon said that the fall resulted to a knock knee and the patient would need to have another surgery to fix the problem. A review of Patient A's record from the Orthopedic Surgeon, indicated the following: - On June 9, 2024, "...presenting today with persistent right knee pain...X-ray (a type of electromagnetic radiation used to create image s of the inside of the body) was negative for any hardware malalignment or periprosthetic fracture (a break in the bone that occurs around an artificial joint)..." - On July 10, 2024, "...Follow-up right knee surgery...The patient has (family member) informs us that when the patient (Patient A) fell the [sic] wheelchair that she was going to sit in did not have breaks [sic]. So, the wheelchair moved, and the patient fell on the ground...Incision is healing well...She does have a valgus deformity (knock knee) of the right knee with the weight bearing and at rest...The patient require to have x-rays performed due to she does have a valgus deformity of the right knee with weight -bearing and also while sitting. We needed to evaluate the deformity...Plan...Because of the patient's fall at the skilled nursing facility. The patient did sustain an injury to the tibial plateau (upper outer part of the shin bone) which caused her tibial plateau to collapse when she fell. The patient now has a valgus deformity [same as genu valgum] of the right knee. The patient will require further revision of the right knee..." Further review of Patient A's record from the Orthopedic Surgeon indicated Patient A has a radiologic examination (x-ray) of the right knee on the following: - On June 9, 2024, "Xr (X-ray) Knee 3 Views Right...No acute periprosthetic fracture..." - On July 10, 2024, "...The 3 images do show a valgus deformity of the right knee. The tibial compartment (one of the sections of the lower leg around the shin bone) has collapsed on the lateral aspect of the right knee...Collapsing of the lateral tibial plateau..." On July 15, 2024, at 2:50 p.m., during an interview, CNA 2 stated the facility had a KARDEX (a medical information system used to keep track of patient’s care plans and essential details) to provide information regarding a patient. CNA 2 stated the patient’s KARDEX indicated Patient A required two-person support for transfer. CNA 2 stated CNAs should use a gait belt to help patient during transfer. On July 15, 2024, at 4:30 p.m., during observation, Patient A was observed with her right knee close to left knee, the right leg was angled outward, with lower extremities in "K" shape. A review of Patient A's KARDEX from June 12, 2024; to July 15, 2024, indicated, "...Mobility...Resident (Patient A) uses recliner to relieve low back pain and increase mobility...two staff assist with transferring…” A review of the facility policy and procedure titled, "Falls, and Risk, Managing," dated 2001, indicated, "...The staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of fall..." A review of the facility policy and procedure titled, "Transfers," (undated), indicated, "...General Principles of Transferring...Use a second person to assist you when indicated...Use appropriate equipment. A transfer belt gives you control of the resident without restricting the resident from assisting you...Type of transfers...Stand Pivot...Verify that the wheelchair's leg rests are out of the way and that the brakes are locked on both the bed and the wheelchair...Take a position on the weaker side or in front of the resident..." A review of American Nurse Journal, titled, "Gait belts 101: a tool for patient and nurse safety," dated May 13, 2019, indicated, "...Tips for assessing patient mobility and using gait belts ...Mobility safety tips...Because gait belts allow patients to participate in transfers...use gait belts to safely steady patients..." Based on interview and record reviews, the CDPH determined that the facility failed to: a. Provide a two-person assist for Patient A during transfer from a regular chair to a wheelchair on June 18, 2024. b. Use a gait belt to assist Patient A during transfer from a regular chair to wheelchair on June 18, 2024. c. Ensure the wheelchair’s brake was operating properly (wheels will not roll/move when locked) during patient’s transfer to the wheelchair. These failures resulted in a fall which led for the patient to sustain injury to the tibial plateau subsequently causing development of genu valgum deformity. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.