Health inspection·February 15, 2024

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. Based on interview and record review, the facility failed to ensure an environment free of accidents when one of three sampled residents (Resident 1) fell during mechanical lift transfer. This failure resulted in Resident 1 sustaining lots of bruises to the body and had been feeling fearful during transfers. Findings: During a review of Resident 1 ' s activity of daily living (ADL) care plan (CP) dated 1/31/20, the CP indicated Resident 1 had self-care deficit and decreased physical mobility due to generalized weakness, may use Hoyer lift (a mechanical lift with a sling) for transfer with two people assist. During a review of Resident 1 ' s minimum data set (MDS, a clinical assessment) dated 10/28/23, the MDS indicated Resident 1 ' s brief interview of mental status (BIMS, a brief cognitive screening measure that focuses on orientation and short-term word recall) score 12, which indicated Resident 1 was cognitively intact. During an interview on 2/7/24 at 1:15 p.m. with Resident 1, the resident stated the CNA [certified nursing assistant] was trying to transfer her from the chair to bed, then the strap of the Hoyer pad snapped, and she fell. She was not sure where she had landed, but she was having pain after the fall and got a huge bruise to the left side of her body. She further stated she still didn ' t feel safe and felt apprehensive every time during transfer. During an interview on 2/7/24 at 1:38 p.m. with CNA A, CNA A stated she was going to give Resident 1 a shower the day after the incident, then she found a lot of bruises on the resident ' s body. The resident told her she fell during Hoyer lift transfer the night before. CNA A reported to the charge nurse right away. She also stated if a resident required a Hoyer lift, there should always be two people assist with the transfer. During an interview on 2/7/24 at 2:05 p.m. with the Director of Nursing (DON), the DON stated the CNA was transferring Resident 1 with a Hoyer lift by herself, but she should have had another staff with her during the transfer, everybody knew that. The CNA also should have reported the incident as a fall. She further stated the facility didn ' t have a system on monitoring and changing the Hoyer lift pads prior to the incident. During an interview on 2/9/24 at 2:30 p.m. with Licensed Vocational Nurse (LVN) B, LVN B stated the CNA did not report the fall to her, the CNA only told her that Resident 1 ' s Hoyer lift pad strap was broken and she believe the CNA was alone during the transfer. The incident was considered a Page 1 of 2 555835 555835 02/15/2024 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall, and the CNA should have reported it to her. She further stated it was everybody ' s responsibility to make sure the equipment worked properly prior to the transfer. During a review of the facility ' s policy and procedure (P&P) titled Fall Precautions – Resident Care, revised December 2017, the P&P indicated, 1. The definitions cited below relate to this policy. 1.1 A Fall is defined as a sudden, involuntary and/or unanticipated drop to a lower position that may or may not result in a physical injury. During a review of the facility ' s P&P titled No-Lift Transfers, revised December 2017, the P&P indicated, 3. Various lifts are available for staff to use. 3.1 The sling lift is utilized for transferring a non-weight bearing resident who is largely bedridden from bed to chair and back. It offers full support for several positions from lying to sitting. [ .] 3.3 Two staff members are present whenever a lift is being used. 555835 Page 2 of 2