Health inspection·December 8, 2023

F689 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/23/2023 the California Department of Public Health (CDPH) received a complaint alleging that a resident (Resident 1) fell from a mechanical lift (a device used to ensure the safe transfer of patients from one location to another) due to the strap not being hooked correctly and the resident sustained a fracture to the shoulder and multiple rib fractures. Resident 1 was transferred to a General Acute Care Hospital (GACH) because of pain and the development of pneumonia where he regressed and passed away. On 10/24/2023, at 10:33 a.m., an unannounced visit was made to the facility to investigate the allegation. Upon investigation, the CDPH determined Resident 1 fell from a mechanical lift onto his bed during a transfer. The facility failed to: Ensure Resident 1 was placed securely in the sling (part of a lift system placed under and around patients who have mobility issues to assist them to be lifted and transferred safely from a bed, wheelchair, toilet, or shower) of a mechanical lift prior to being transferred from his bed to his wheelchair. As a result of this deficient practice, Resident 1 fell from a mechanical lift onto his bed and sustained a fracture (partial or complete break in the bone) of his clavicle (the collar bone) and his rib. Resident 1 was transferred to a GACH for evaluation, treatment, and a Computed Tomography scan ([CT scan] a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of his head. A review of Resident 1's Admission Record (Face sheet) indicated that Resident 1 was a 66-year-old male, who was initially admitted to the facility on 3/22/2022 and re-admitted on 12/28/2022. Resident 1 had diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction (a stroke) affecting the left dominant side of Resident 1's body, epileptic seizures (a disorder of the brain causing uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms) and a nontraumatic intracranial hemorrhage (bleeding into the brain in the absence of trauma or surgery). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/29/2023, indicated, Resident 1's cognition (thinking, attention, language, learning, memory, and perception) was intact. Resident 1 required an extensive one-person physical assist for bed mobility. Resident 1 was totally dependent and required a two-person physical assist for transfers and toilet use. A review of Resident 1's Care Plan, dated 4/5/2022, indicated Resident 1 had an activity of daily living ([ADL] activities related to personal care) self-care performance deficit related to hemiplegia and hemiparesis. The goals indicated, Resident 1 would improve his functional abilities with less support from staff while maintaining comfort and safety. The Care Plan interventions indicated, Resident 1 required assistance and may use a mechanical lift for transfers. A review of Resident 1's Nursing Progress Notes, dated 6/13/2023 and timed at 5:15 p.m., indicated, at approximately 12:30 p.m., Resident 1 was found on the floor with his head on the lap of Certified Nurse Assistant (CNA) 1. The Progress Notes indicated CNA 1 reported that Resident 1 had an assisted fall while being transferred from his bed to his wheelchair using a mechanical lift. The Progress Notes indicated Resident 1 had a bump on his left forehead and Resident 1 reported he hit his head but stated he did not remember where he hit his head. The Progress Notes indicated Resident 1's physician was called, and an order was obtained to transfer Resident 1 to a GACH for further evaluation and a CT scan of Resident 1's head. A review of Resident 1's Situation, Background, Assessment, & Recommendation ([SBAR] a form of communication between members of a health care team) dated 6/13/2023 and timed at 1:14 p.m., indicated, Resident 1's left upper extremity was sensitive to touch, he was unable to move, and he had a left forehead bump with discoloration and slight bleeding at the site that was sensitive to touch. A review of Resident 1's Physician Orders, dated 6/13/2023, indicated, to transfer Resident 1 to a GACH emergency room (ER) for further evaluation after Resident 1 fell and sustained a head injury. A review of Resident 1's Nursing Progress notes, dated 6/13/2023 and timed, at 6:29 p.m., indicated, Resident 1 was picked up by an ambulance and transported to the GACH. A review of the GACH's CT report of Resident 1's chest dated 6/13/2023, and timed at 8:01 p.m., indicated, Resident 1 had a nondisplaced (a fracture in which the bone cracks or breaks but retains its proper alignment) left sixth posterior (direction toward the back of the body) rib fracture. A review of the GACH's X-ray of Resident 1's left shoulder, dated 6/13/2023, and timed at 9:56 p.m., indicated, Resident 1 had an anterior (front) subluxation (dislocation) of the left humeral head (shoulder) and a nondisplaced fracture of the distal (away from the trunk of the body) left clavicle. A review of the GACH's Emergency Department (ED) Physician Notes, dated 6/13/2023 and timed at 10:36 p.m., indicated, Resident 1 had a shoulder reduction (the process of returning the shoulder to its normal position following a shoulder dislocation) and Resident 1's left shoulder was placed in a sling (a device that keeps the arm against the body and prevents too much movement). During an interview on 10/24/2023, at 1:09 p.m., CNA 1 stated, there should be two people assisting while using a mechanical lift at all times. CNA 1 stated, regarding the fall incident on 6/13/2023, she looked for assistance to transfer Resident 1, but everyone was busy, and Resident 1 told her to hurry up because his family was visiting so she transferred Resident 1 using the mechanical lift alone without assistance from another staff member. CNA 1 stated, she put the sling under Resident 1's body and placed the hooks from the mechanical lift into the sling's openings. Resident 1 held onto the bar on the mechanical lift with his right hand while she lifted him using the mechanical lift. CNA 1 stated, one of the hooks on the upper left side of the sling came off and Resident 1 fell on top of the upper left side of his bed. CNA 1 stated Resident 1's legs were still in the sling and hanging from the mechanical lift and he was at an angle diagonally across his bed. CNA 1 stated she lowered the mechanical lift and Resident 1 fell onto the bed with his body slightly raised in the air while still attached to the sling that was still attached to the mechanical lift. Resident 1's right foot was hanging off the bed touching the ground and his left leg was on the bed. CNA 1 stated Resident 1 was holding onto her and would not let her go. Resident 1 was too heavy, and she had to lower Resident 1 onto the floor. CNA 1 stated she used the mechanical lift alone, because everyone was busy, and she felt confident enough to transfer Resident 1 on her own. CNA 1 stated it was important to use two people to assist when using the mechanical lift to keep the resident safe. CNA 1 stated she was instructed during in-services that two people were to always be present and assist when using a mechanical lift. During an interview on 10/24/2023, at 2:50 p.m., Licensed Vocational Nurse (LVN) 1 stated, when CNA 1 reported to her that Resident 1 fell, she (LVN 1) went to Resident 1's room where she saw Resident 1 on the floor next to his bed. LVN 1 stated she assessed Resident 1 and noted a bump on the left side of Resident 1's head. During an interview on 10/24/2023, at 3:01 p.m., Registered Nurse Supervisor (RNS) 1 stated, two people were needed to transfer a patient using a mechanical lift. RNS 1 stated, CNA 1 reported that she was transferring Resident 1 from his bed to his wheelchair when Resident 1 slipped from the mechanical lift. RNS 1 stated when she entered Resident 1's room, CNA 1 was holding Resident 1's head in her lap and CNA 1 told her that she (CNA 1) caught Resident 1 when Resident 1 slipped from the mechanical lift. RNS 1 stated she assessed Resident 1 and found a bump on Resident 1's left forehead During an interview on 10/24/2023, at 3:37 p.m., the Director of Staff Development (DSD) stated, if a resident could only use one side of his body, then two people should assist when using a mechanical lift. The DSD stated Resident 1 required two people to transfer him using a mechanical lift because Resident 1 had left sided weakness and Resident 1's right side might not be strong enough to hold onto the mechanical lift. The DSD stated this injury was avoidable if the policy and procedure had been followed. The DSD stated, staff should make sure the sling is safely secured on the hooks of the mechanical lift, the second person provides a second check for safety and supports the upper back of the resident during the transfer. The DSD stated if everyone was busy, CNA 1 should have waited until someone came to assist before transferring Resident 1 by herself. During an interview on 10/25/2023, at 4:39 p.m., Director of Nursing (DON) 2 stated, it was reported to her that Resident 1 slipped from a mechanical lift, complained of chest pain, and was transferred to a GACH for a CT scan. DON 2 stated the hooks of the mechanical lift that go into the sling should have been checked to make sure the hooks were secured properly, and CNA 1 must have missed a step when using the mechanical lift. DON 2 stated the importance of using two people and checking that the hooks were secured properly was to prevent an accident such as a fall from the mechanical lift. A review of the facility's Policy and Procedure (P/P), titled "Lifting Machine, using a Portable," revised 4/2007, indicated the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two nursing assistants will be required to perform the procedure. The facility failed to: Ensure Resident 1 was placed securely in the of a mechanical lift prior to being transferred from his bed to his wheelchair. As a result of this deficient practice, Resident 1 fell from a mechanical lift onto his bed and sustained a fracture of his clavicle and his rib. Resident 1 was transferred to a GACH for evaluation, treatment, and a CT scan of his head. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.