Other·July 18, 2023

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 830905. The inspection was limited to the specific FRIs investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: HFEN #34401 A deficiency was written for FRI #830905 at F-tag 689/G. 42 Code of Federal Regulations, part 483.25 (d)(1) & (d)(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 accidents. On 3/15/23, at 10:10 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's fall with injury. Resident 1 was transferred from bed to the wheelchair without the use of a Hoyer lift ([a commonly use brand] mechanical lift are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical support), resulting in Resident 1 falling and sustaining a right ankle fracture. On 9/13/22, the facility admitted Resident 1, a 62-year-old female, with diagnoses of End Stage Renal Disease (where kidney function has declined to the point that the kidneys can no longer function on their own), Diabetes, Depression, and Transient Ischemic Attack (stroke like symptoms occurs when the blood supply to part of the brain is briefly interrupted. Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool) dated 1/18/23, the MDS indicated, Resident 1 had a BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 12 (scores range from 0 - 15 and a score of 8-12 demonstrates moderately impaired cognition). The MDS indicated, Resident 1 required extensive assistance with "two+ person physical assist for transfer [how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position. . .]." Resident 1 was "Not steady, only able to stabilize with staff assistance" when moving from seated to standing position. Based on observation, interview, and record review, the facility failed to follow the plan of care for one sampled resident (Resident 1) when the facility failed to use a Hoyer lift to transfer the resident from her bed to the wheelchair. This failure resulted in Resident 1 falling to the floor, sustaining a right ankle fracture (broken bone). Findings: During an interview on 3/15/23, at 10:10 AM, with Director of Nurses (DON), DON stated, on 3/9/23, at approximately 8 AM, Certified Nursing Assistant Students (CNAS) 1 and CNAS 2, transferred Resident 1 from her bed to the wheelchair without the use of a Hoyer lift. During the transfer, Resident 1's knees buckled (bend), and a "pop" was heard in Resident 1's right ankle. CNAS 1 and CNAS 2 then eased Resident 1 to the floor. DON stated, on 3/9/23, Resident 1 sustained a right ankle fracture. During a concurrent observation and interview on 3/15/23, at 11:33 AM, in Resident 1's room, Resident 1 was noted lying in bed. Resident 1 stated, "I had the two girls [CNAS 1 and CNAS 2] stand me up and just two seconds of standing, my knees gave out and I slid onto the floor." During an interview on 3/15/23, at 1:17 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 requires two-persons to assist the resident with transfers using a Hoyer lift. LVN 1 stated, Resident 1 had upper body strength but "doesn't have a lot of strength in her lower legs." LVN 1 stated, Resident 1's fall incident on 3/9/23, could have been prevented if a Hoyer lift was used to transfer Resident 1 from the bed to the wheelchair. During an interview on 3/15/23, at 1:18 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she has worked with Resident 1 for approximately six months and was very familiar with Resident 1's care. CNA 1 stated, Resident 1 could not bear weight and required two-person assistance with the use of a Hoyer lift with transfers. During an interview on 3/15/23, at 1:25 PM, with CNA 2, CNA 2 stated, he has worked with Resident 1 for approximately nine months and is very familiar with Resident 1's care. CNA 2 stated, Resident 1 is unable to bear weight and requires two-person assistance in transferring from the bed to the wheelchair using a Hoyer lift. CNA 2 stated, Resident 1's fall incident on 3/9/23, could have been prevented if a Hoyer lift was used during the transfer from the bed to the wheelchair. During an interview on 3/15/23, at 1:45 PM, with Physical Therapy Assistant (PTA), PTA stated, Resident 1 was "weak. . .unsafe. . .we recommended Hoyer lift during transfer." PTA stated, therapy staff have attempted to assist Resident 1 to walk but "once we started the session, she couldn't, her knees would start buckling [bending]." During an interview on 3/15/23, at 2:08 PM, with CNAS 1, CNAS 1 stated, on 3/9/23, Resident 1 requested to be changed and dressed. CNAS 1 stated, Resident 1 was on the heavy side, and she asked CNAS 2 to help her transfer Resident 1 from the bed to the wheelchair. CNAS 1 stated, she stood behind Resident 1's wheelchair to prevent the wheelchair from rolling back while she observed CNAS 2 transfer Resident 1 from the bed to the wheelchair. CNAS 1 stated, "[CNAS 2] had her [Resident 1] in a sitting position on the edge of the bed with gait belt [assistive device used to transfer residents from one location to another] around her waist. . .she [Resident 1] was able to stand but she started saying my knees are giving out. . .she [CNAS 2] tried to lift her [Resident 1] but she was too heavy, so she [CNAS 2] just placed her [Resident 1] to the ground." CNAS 1 stated, she did not know Resident 1 required a Hoyer lift to transfer. During an interview on 3/15/23, at 4:04 PM, with CNAS 2, CNAS 2 stated, on 3/9/23, she went to Resident 1's room with CNAS 1. CNAS 2 stated, after they (CNAS 1 and CNAS 2) changed Resident 1's adult brief and clothes, they (CNAS 1 and CNAS 2) attempted to transfer Resident 1 from the bed to the wheelchair. CNAS 2 stated, "She [Resident 1] was telling us she was a little scared and nervous. . .she said she needed a sling [used for safe lifting], we didn't know what it was for at first, we kept trying to stand her and at the last try, she started falling, her leg went behind her. . .she was wobbly [unsteady] when we stood her up." CNAS 2 stated, she did not know Resident 1 required a Hoyer lift with transfers. During an interview on 3/15/23, at 4:23 PM, with Student Instructor (SI), SI stated, the students had only been at the facility for two days. SI stated, on 3/9/23, all students were instructed to only answer call lights. SI stated, "My students cannot transfer anybody without me or CNA in the facility present." SI stated, both CNAS 1 and CNAS 2 have not been signed off on their transferring competency. SI stated, "They [CNAS 1 and CNAS 2] should not have transferred her [Resident 1]." During a concurrent interview and record review on 5/9/23, at 11:37 AM, with DON, Resident 1's "Care Plan" (CP), dated 10/28/21, was reviewed. The CP indicated, "I have a physical functioning deficit related to generalized weakness." Intervention included "Transfer assistance of 2 person assist with use of Hoyer for all transfers." DON confirmed the findings and stated Resident 1 required a Hoyer lift for transfers. During a review of Resident 1's right ankle "Radiology Report" (RR), dated 3/9/23, the RR indicated, "Findings: . . .There are fractures of the distal tibial and fibular diametaphysis [ankle fracture]." During a review of the facility's policy and procedure (P&P) titled, "Safe Resident Handling/Transfers," dated 5/1/22, the P&P indicated, "It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident. . .All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. . . 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. In violation of the above-cited standards, the facility failed to ensure Resident 1 was transferred using a Hoyer lift which resulted in Resident 1 falling and sustaining a right ankle fracture. This 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 is a class A citation.