Health inspection·July 8, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was transferred from chair to bed by using a Hoyer lift (a device used for lifting and safely transfering residents) with a sling (an assembly which connects the load to the Hoyer lift). This failure resulted in harm when Resident 1 sustained bruises on right upper inside of the arm and left upper inside of arm. Findings: During a review of the clinical record for Resident 1 title, admission Record, indicated Resident 1 was admitted to the facility on [DATE], with the admitting diagnosis of: Unspecified Fracture of T9 - T10 Vertebra (T9 Thoracic [midback] is Fracture is a serious injury that can lead to long term complications and T10 Thoracic vertebra fracture will be likely result in a limited or complete loss of use of lower abdomen muscles .), Seizures (uncontrolled burst of electrical activity in the brain) and Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pressure or interest in life). During an observation on June 16, 2023 at 1:45 PM in Resident 1's room, Resident 1 was on a sitting up position, with head of the bed elevated to 90 degrees angle. Resident 1 was awake, alert, and oriented and able to verbalize his needs. Resident 1 was wearing a C-collar (a device used to support and immobilize a patient's neck) and TLSO brace (a brace that limits movement in the spine form the midback to the low back). During an interview on June 16, 2023, at 1:45 PM, in Resident 1's room, Resident 1 stated that on Saturday June 10, 2023, while he was sitting on his chair, 2 staff Certified Nurse Assistants (CNA 1 and CNA 2) came to assist him back to his bed. Resident 1 told them he wanted them to use the Hoyer lift with a sling but instead CNA 1 lift him from his arms and CNA 2 grabbed his feet, and place him on bed. Resident 1 stated they left bruises on him under his upper arms area. During a Concurrent observation and interview on June 16, 2023, at 2:10 PM with Registered Nurse (RN 1), RN 1 identified the bruises on Resident 1's arms. RN 1 stated according to Resident 1, it occurred when CNA 1 and CNA 2 transferred him back to bed and did not used the Hoyer lift with a sling. RN 1 futher stated they knew Resident 1 need the Hoyer lift with a sling when transferring but CNA 1 and CNA 2, failed to use to Hoyer lift with a sling. During an interview on June 16, 2023, at 3:56 PM, via phone with Director of Nurses (DON), the DON Page 1 of 2 555494 555494 07/08/2023 Cedar Mountain Post Acute 11970 4th St Yucaipa, CA 92399

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that she was informed on June 13, 2023, that Resident 1 was handled out of his chair and back to bed by 2 staff members on Saturday night. It was reported to the DON that Resident 1 wanted to go back to bed, and that CNA 1 and CNA 2 transferred Resident 1 without using a Hoyer lift with a sling. The DON stated CNA 1 and CNA 2, did not give a reason of why they failed to use the Hoyer lift with a sling, while transferring Resident 1 back to bed. When DON did an assessment of Resident 1's skin, DON identified the bruises on Resident 1 arms. DON stated, that immediately suspended the CNA 1 and CNA 2 and then, both CNAs got terminated the following day. DON acknowledge that the CNA 1 and CNA 2, failed to follow the lifting policy while transferring Resident 1. During an interview on June 21, 2023, at 1:08 PM via phone with the administrator (ADM) , the ADM stated that she was informed about the incident on June 13, 2023, while doing her rounds. She was informed by Resident 1 about the bruises. ADM stated that she informed Resident 1 that she was going to have the DON to check on him immediately. ADM stated that after the investigation the two employees were terminated. ADM agreed that CNA 1 and CNA 2 failed to follow the facility's policy of using the Hoyer lift with a sling with Resident 1. During a review of clinical record title, Clinical Care Plan Detail, undated, indicated for intervention to: Utilize C collar brace per resident request of use, Use Hoyer, and proper sling to transfer . During a review of clinical record title, eINTERACT Change in Condition Evaluation - V 5.1, dated June 13, 2023, at 2:17 PM indicated, 1. Signs & Symptoms Identified 1. The change in condition, symptoms, or signs I am calling about is/ are: 36. Change in skin color or condition 2. This started on: June 10, 2023 .4. Summarize your observations, evaluation, and recommendations: Resident was lifted by 2 cna back to bed using his bil forearms to transfer and other cna had his feet resident had a sling under him and failed to use the Hoyer. CNA stood behind resident while he was in the wheelchair and grabbed his forearms . 2. Skin Status Evaluation 6a. Describe skin changes: 5. Discoloration Site Description nickel size red purple area to rt [Right] upper arm quarter quarter size red area with skin peeling to left upper inside of arm . During a review of the facility's policy and procedure title, Lifting Machine, using a Mechanical indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .2. Mechanical lifts may be used for tasks that require transferring a resident from bed to chair . 555494 Page 2 of 2