Health inspection·May 31, 2024

California Code Regulations, Title 22, section 72311 -Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code Regulations, Title 22, section 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. Code of Federal Regulation, Title 42, 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. On March 28, 2024, at 3:10 p.m., an announced visit to the facility was conducted to investigate quality-of-care issue. It was determined that the facility failed to ensure a female patient with lower extremity contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) was properly positioned during urinary catheterization (a procedure when a flexible tube is inserted into the bladder to drain urine) for urine sample collection. This failure resulted in Patient A to sustain a left hip fracture (broken bone) and was subsequently transferred to the general acute care hospital (GACH) for a surgical procedure. On March 28, 2024, at 3:43 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she worked as a charge nurse on the morning shift on March 13, 2024. RN 1 stated Patient A's had change of condition and the physician ordered a urinalysis (laboratory urine test). RN 1 stated the Licensed Vocational Nurse (LVN) 1 reported hearing a "pop" from the patient's hip area while trying to collect urine from Patient A. Thereafter, the physician ordered an x-ray (a photographic or digital image of the internal composition of a part of the body), which RN 1 stated indicated a fracture on the femur (hip). She stated Patient A was subsequently transferred to the GACH. On March 28, 2024, at 4:02 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she assisted LVN 1 in collecting urine from Patient A on March 13, 2024. CNA 2 stated she was at the left side of Patient A and CNA 1 was at the right side of the patient. CNA 2 stated they (CNA 1, CNA 2, and LVN 1) heard a "pop" when she lifted the patient's left leg. CNA 2 stated she lifted Patient A's leg by placing both hands under the patient's left leg and lifting it about six inches up from the mattress and CNA 2 stated that was the moment they heard the popping sound from Patient A's left thigh/hip area. She further stated LVN 1 reported to RN 1 that a popping sound was heard from Patient A's left hip and LVN 1 was instructed by RN 1 to continue with the urine sample collection. On March 28, 2024, at 4:36 p.m., an interview with CNA 1 was conducted. CNA 1 stated LVN 1 had asked her and CNA 2 for assistance in getting a urine sample from Patient A on March 13, 2024, at around 11:30 a.m. CNA 1 stated Patient A was very contracted on her upper and lower extremities with her hip towards the left side and the upper body was towards the right side. CNA 1 stated she and CNA 2 lifted Patient A's hip slightly (few inches above the mattress) to spread her legs so that LVN 1 could insert the catheter in her perineal area (area of the body between the anus and the vagina) to collect the urine sample, then they heard a "pop." CNA 1 stated the popping sound came from Patient A's left hip. She stated LVN 1 left the room to report the incident to RN 1 and upon return to the room, LVN 1 told CNAs 1 and 2 that the charge nurse instructed her (LVN 1) to continue with the urine sample collection. She stated, during the second attempt to collect the urine sample, they lifted Patient A the same way (lifting the patient's hip few inches above the mattress) and spread the patient's legs open while another LVN inserted the catheter on Patient A. On March 28, 2024, Patient A's admission record was reviewed. Patient A was admitted to the facility on July 9, 2020, with diagnoses which included chronic respiratory failure (lung failure), status post tracheostomy (a surgical procedure to cut an opening on the neck to aid in breathing), and persistent vegetable state (a person who has loss of awareness of their surroundings). A review of Patient A's "History and Physical," dated January 27, 2024, indicated, "...NEUROMUSCULAR...Restrictive ROM (range of motion -the extent or limit to which a part of the body can be moved around a joint or a fixed point) ..." A review of Patient A's care plan, dated January 27, 2024, indicated, "...Immobility...Contractured (sic) Extremities...Position for comfort..." A review of Patient A's "Progress Notes," indicated the following: - March 13, 3024, at 11:15 a.m.; "...MD (medical doctor) ordered a UA (urinalysis) d/t (due to) residents (sic) change in mental status....while straight cath (catheter), x (times) 2 (two) CNAs assist writer and the x (times) 2 (two) CNAs heard a "pop" noise that came from residents (sic) lip (sic) hip...writer and cnas stopped and and assessed residents left leg and left hip for any changes..." - March 13, 2024, at 11:35 a.m.; "...Notified by LVN performing the urine collection that she heard a POP from the left hip while trying to collect the urine...MD ordered a (sic) X RAY left...Urine was collected and sent to lab..." - March 13, 2024, at 6:10 p.m.; "...After sending left hip X-ray result to MD an order was received to transfer resident to DOU (Direct Observation Unit) under (name of doctor), due to left femur (thigh bone) fracture..." On April 18, 2024, at 3:42 p.m., an interview with RN 1 was conducted. She stated on March 13, 2024, between 10 a.m. to 11 a.m., LVN 1 reported hearing a pop that came from Patient A's left hip when the CNAs lifted Patient A's legs during urine sample collection. She stated LVN 1 reported to RN 1 she did not feel comfortable in continuing to collect the urine sample. RN 1 stated she then asked another LVN to help. RN 1 stated she observed CNAs 1 and 2 lifted the patient by the hip on each side with one hand on the hip and the other hand on the patient's upper leg in which Patient A's lower part of the body was completely suspended several inches from the bed. RN 1 stated she realized she should not have continued getting the urine sample after hearing the report from LVN 1 about the popping sound during the first attempt of urine collection. She also stated she should have stopped the CNAs when they lifted the patient from the hip and legs as she realized that it was probably not the safest positioning of the patient when the urine sample was collected. She further stated they should have attempted to place the patient at side-lying position which could have prevented the fracture. On April 18, 2024, at 4:02 p.m., an interview with LVN 1 was conducted. LVN 1 stated Patient A's legs were very contracted. She described Patient A's legs on both sides to be internally rotated (knee and foot twisted toward the midline of the body) with both knees almost touching each other. She further stated Patient A's legs on both sides could not be extended apart due to contractures. LVN 1 stated while CNAs 1 and 2 were helping her collect the urine sample using a straight catheter, she heard a popping noise when the two CNAs lifted the patient from the hip on both sides on March 13, 2024. She stated she immediately told the CNAs to put down the patient, and she reported the popping sound to RN 1. However, she was told that a urine sample was still needed. She further stated she told RN 1 she did not feel comfortable collecting the sample, so RN 1 asked another LVN to collect a urine sample. LVN 1 stated she observed the CNAs lifted Patient A's hip on both sides the same way they did during the first attempt on urine sample collection. LVN 1 stated after further discussion of the incident, she realized the positioning of Patient A when the urine sample was collected was probably not the safest position to prevent injuries. On April 18, 2024, at 4:19 p.m., an interview with CNA 2 was conducted. CNA 2 stated Patient A's both legs could not be extended apart due to her contractures. She stated on March 13, 2024, she and CNA 1 assisted LVN 1 in collecting the urine sample from Patient A. CNA 2 stated Patient A was lying in bed on her back with both of her knees slightly bent at the knees. CNA 2 stated she was on the left side of the bed while CNA 1 was on the opposite side. CNA 2 stated she and CNA 1 lifted Patient A from her hip on each side with one hand on the hip and other hand right below the upper leg. She stated Patient A's lower part of the body was completely suspended in the air about several inches above the bed while LVN 1 attempted to collect the urine sample. CNA 1 stated while LVN 1 was attempting to collect the urine sample, she and CNA 2 heard a pop that came from Patient A's left hip and immediately put down the patient's lower body in bed. She stated LVN 1 left the room to report the popping sound from Patient A's left hip to RN 1. She stated LVN 1 came back with RN 1 and another LVN to continue with collecting the urine sample. CNA 2 stated they used the same positioning by lifting Patient A's hip and leg as they did on the first attempt of urine collection. On April 18, 2024, at 4:56 p.m., an interview was conducted with the MD. The MD stated she was aware of the incident that occurred on March 13, 2024. The MD stated the staff reported that the patient sustained a fracture on her left hip after the staff attempted to collect the urine sample. She stated she was not aware the CNAs who assisted in collecting the urine sample had lifted Patient A by the hip and legs. She stated due to the Patient A's lower leg contracture, side-lying positioning would have been the safest way to collect the urine sample from Patient A. She stated Patient A's left hip fracture was likely caused by the improper positioning of the patient during urinary catheterization to collect a urine sample. She further stated if the staff reported they heard a pop on the first attempt to collect the urine, she would not have them continue collecting urine sample from Patient A. She stated due to improper positioning by the staff, the patient had to go to the hospital for a surgical procedure. On April 18, 2024, at 5:27 p.m., an interview with the Director of Nursing (DON) was conducted. She stated she was not aware the CNAs who assisted in collecting the urine sample from Patient A had lifted patient from the hip and legs while suspended in the air. She stated this was not the proper positioning to collect the urine sample since she was aware of Patient A's contractures. She stated the staff who was involved during the time of the incident should have attempted to place Patient A in side-lying position instead of being lifted by the hip and legs to prevent injuries to the patient. She also stated RN 1 should not have instructed the LVN to continue with urine sample collection after hearing the report from LVN 1 about the popping sound that was heard after the first attempt. The DON further stated the cause of the fracture was likely due to improper positioning of the patient by the staff, considering the location of the fracture. The DON stated the facility did not have a policy and procedure related to the urine collection through straight catheter. A review of a web article titled "Urinary Catheters- Clinical Procedures for Safer Patient Care," published on 2015, indicated, "...Positioning of patient depends on gender...Patients should be comfortable, with perineum (an area between the anus and vagina) or penis exposed, for ease and safety in completing the procedure...Female patient: On back with knees flexed and thighs relaxed so that hips rotate to expose perineal area. Alternatively, if patient cannot abduct leg at the hip, patient can be side lying with upper leg flexed at knee and hip, supported by pillows..." A review of the facility's policy and procedure titled "General Restorative & Supportive Nursing Care," dated April 4, 2021, indicated, "...It is the policy of this facility that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities...Restorative and supportive care shall include...Maintaining good body alignment and proper positioning of bedfast and dependent residents..." A review of Patient A's "(name of hospital) Discharge Summary," dated March 21, 2024, indicated, "...ADMISSION DIAGNOSES: Left hip fracture...HOSPITAL COURSE: The patient...was getting a urinalysis when the nurse heard a popping sound on the left hip. X-ray was done showing a left hip fracture...The patient with left hip fracture, status post repair with ORIF (open reduction and internal fixation [a type of surgery used to stabilize and heal a broken bone]) by (name of doctor) ..." Based on interview and record review, the facility failed to ensure a female patient with lower extremity contractures was properly positioned during urinary catheterization. This failure resulted in Patient A sustaining a left hip fracture and was subsequently transferred to the GACH for a surgical procedure. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were substantial factors of Patient A's left hip fracture.