Health inspection·November 9, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record Review, this requirement was not met when staff caused pain and redness to a resident ' s foot, resulting in a delay in the progress toward his rehabilitation goals. Findings: A review of the Clinical Record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation of worsening contractures (rigidity, shortening and hardening of the muscles and tendons) in his feet; Resident 1 was wheelchair bound. Review of Resident 1 ' s Minimum Data Set (MDS) Section G, Functional Status, dated 9/7/23, indicated that Resident 1 required Extensive Assistance for transferring from one surface to another, moving side to side in bed, toilet use, and dressing. Review of the facility ' s record titled Physical Therapy Evaluation and Plan of Treatment dated 9/4/23 indicated, Patient admitted to [a nearby hospital] for evaluation and now being seen here secondary to significant loss of function with both lower extremities exhibiting extensor tone [spasticity of the muscle that straightens the foot] and drop foot (difficulty in lifting the foot) with inability to stand or ambulate [walk]. The record further indicated that Resident 1 was at risk for contracture(s), decreased ability to return to prior living environment, decrease in level of mobility .further decline in function, immobility, and increased dependency upon caregivers, and, muscle atrophy, the deterioration of muscle from disuse. Review of the facility ' s Job Description for Restorative Aide date 4/1/22, indicated that the Restorative Nursing Aide (RNA) provides restorative nursing therapy treatments to residents to help resident attain/maintain their highest level of function. Review of the facility ' s Occupational Therapy Evaluation and Plan of Treatment dated 9/7/23 indicated that resident was receiving skilled Occupational Therapy services to maximize rehab potential, increase functional activity tolerance [ability to tolerate exercise], facilitate sitting tolerance [ability to sit in wheelchair for extended periods], and postural control [ability to sit up straight]. Review of an Occupational Therapy Treatment Encounter Note dated 10/25/23 indicated that on 10/25/23, Resident 1 reported that while being cared for by RNA 1, his left lower extremity had been pushed on and was very sore, and that an area of redness was seen on that day that was more bright in color, and that later the area was observed to be purplish in color. The record further indicated that Resident 1 stated that his foot was sore from [RNA 1] ' bouncing ' when stretching his foot to put on a supportive splint for his foot drop. Page 1 of 3 555281 555281 11/09/2023 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0688 Level of Harm - Minimal harm or potential for actual harm Review of a Nursing Progress Note dated 10/24/23 indicated that Resident 1 ' s foot stretching was suspended due to his injury, being replaced by Rest, Ice and Elevation. Review of a Physical Therapy Treatment Encounter Note dated 10/25/23, indicated that foot stretching was declined at this time due to deep pain to left foot and bruising. Residents Affected - Few Review of a document titled In-service Education Summary dated 10/27/23 indicated that Resident 1 ' s foot was wrapped in an ace bandage from 10/27/23 to 10/29/23 and that Physical Therapy will reassess patient on 10/30/23. Review of the record, Physical Therapy Treatment Encounter Note(s), dated 10/31/23 (six days following Resident 1 ' s soreness), indicated a lack of progress in therapy: Patient ' s contractures remain nearly unchanged. Review of a later record, Physical Therapy Treatment Encounter Note(s), dated 11/1/23, indicated that a skin inspection revealed a purplish. In a concurrent interview and observation on 11/7/23 at 8:55 AM, Resident 1 appeared to have foot drop with thickened, contracted (spastic, shortened) feet. Resident 1 stated that on 10/24/23, RNA1 was assisting him in stretching his foot to put it into a supportive ankle brace. Resident 1 stated that RNA A bounced his foot rather than pressing in a slow, continuous motion with even pressure. This resulted in a reddened area developing, and pain that prevented him from getting out of bed or into his wheelchair. Resident 1 stated, My whole goal here is to be able to get in and out of my wheelchair by myself, and that, because he was injured while putting on his brace, he was in bed for several days and lost progress toward his goal. Resident 1 further stated that it has been his personal goal to spend 8 hours a day in his wheelchair so he can get in and out of it safely. Resident 1 further stated, Why in the world would anyone bounce your foot to stretch it? It should be slow and easy. Maybe [RNA A] wasn ' t trying to hurt me, I don ' t know, but he ' s a strong kid and it hurt. Resident 1 stated that he had been married to a kinesiologist (a professional who is an expert body movement), and that he was very familiar with the right way a stretch should be done. Resident 1 further stated, I feel that I had to spend a whole weekend in bed without putting on my braces. Every day without my braces or getting into my wheelchair is lost progress in my therapy goals. In a concurrent observation, Resident 1 produced a photograph that was date and time stamped 10/24/23 at 4:23 PM of a raised, reddened area on the dorsal (back) aspect of his left foot that appeared to be 5 cm (less than two inches) long and 1.5 cm wide. Another photo stamped 4:24 PM on that same date showed the area distinctly darker and slightly purple. In an interview on 11/7/23 at 10:15 AM, Assistant Director of Rehabilitation (ADR B) was asked about the correct way of stretching a resident, whether it be bursts of pressure or slow, steady pressure. She stated, You definitely don ' t just push, noting that it could cause pain. In an interview on 11/7/23 at 11:05, RNA A acknowledged the incident. RNA A recalled that he was stretching Resident 1 and stated he was fighting some tone [muscle rigidity], when he stretched Resident 1's foot, and that any bouncing would have been from the recoil. RNA A stated that putting a brace on a contracted foot is usually a two-person job, one person applying pressure while the other person puts the brace on, and acknowledged that he provided services without a second person that day. 555281 Page 2 of 3 555281 11/09/2023 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 11/7/23 at 4:20 PM, Physical Therapy Assistant (PTA D) stated that she would never refer to proper stretching as fighting the tone, and that periods of stretching should be prolonged, no less than 30 seconds, rather than bursts. Additional review of several records indicated that bursts of stretching are not considered best practice in a therapeutic setting: 1) The American College of Sports Medicine ' s Resources for the Exercise Physiologist, Second Edition, dated June 2013, further indicated that ballistic stretching involves rapid and bouncing-like movements that uses the body ' s momentum and recoil to stretch a muscle. The document indicated that, this type of stretching technique, as opposed to static stretching .is no longer advocated as common practice for most individuals to improve a joint ' s range of motion, and 2) International Journal of Sports Physical Therapy dated February 2012, indicated that there are two types of stretching: 1) Dynamic stretching in which a constant, slow force is placed on a joint, and 2) Ballistic stretching, or rapid, alternating movements or ' bouncing ' at end-range of motion, and that because of increased risk for injury, ballistic stretching is no longer recommended. 555281 Page 3 of 3