Health inspection·December 29, 2023

F689 §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 10/18/2023, the California Department of Public Health (CDPH) received a complaint that a resident (Resident 1) was lifted by her robe while being transferred to her wheelchair. Resident 1fell and suffered injuries to both of her knees. On 11/2/2023 an unannounced visit was made to the facility to investigate the complaint regarding Resident 1’s fall. During the investigation, CDPH determined Resident 1, who could not bear weight on her left leg, was transferred from her bed by two Certified Nurse Assistants (CNA 1 and CNA 2) without the assistance of a mechanical lift. Resident 1 fell during the transfer. The facility failed to: 1. Ensure Resident 1, who could not bear weight on her left leg, was transferred using a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone), as specified in Resident 1’s care plan and on Resident 1’s nursing assessment and Kardex (a communication tool used to relate important care information regarding residents’ care needs such as assistance with transferring). 2. Ensure the nursing staff followed their policy and procedure (P/P), titled, “Safe Lifting and Movement of Residents,” which indicated, in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. As a result, CNA 1 and CNA 2 attempted to transfer Resident from her bed to a wheelchair by physically lifting her from underneath her arms. During the transfer, CNA 1, and CNA 2 lost control of Resident 1, resulting in Resident 1 sliding from her bed and landing on the floor on her knees. Resident 1 was found with swelling, bruising, and an abrasion (a scrape) to her left knee and was subsequently assessed with swelling and effusion (a buildup of fluid inside of the joint such as a swollen ankle or knee) to her left knee with an order to apply a topical antibiotic to her left knee abrasion for 14 days. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1 was originally admitted to the facility on 12/17/2019 and readmitted on 1/15/2020. The Face Sheet indicated Resident 1’s diagnoses included hemiplegia (paralysis on one side of the body), hemiparesis (weakness or inability to move on one side of the body) affecting Resident 1’s left nondominant side, a history of falling, age related osteoporosis (a medical condition in which the bones become brittle and fragile), and foot drop (difficulty lifting the front part of the foot) of Resident 1’s left foot. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/11/2023, indicated Resident 1 made independent decisions that were reasonable and consistent. The MDS indicated, Resident 1 required extensive one-person physical assist for bed mobility and transfers and was totally dependent on nursing staff requiring a two-person physical assist for surface-to-surface transfers. The MDS indicated Resident 1 was not steady during surface-to-surface transfers (transfers between bed and chair or wheelchair) and was only able to stabilize with staff assistance and Resident 1 had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to one leg and one arm. A review of Resident 1’s Care Plan, dated 12/16/2020, indicated Resident 1 required total assistance by two staff to move between surfaces and Resident 1 utilized a mechanical lift (a device used to move residents who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) for transfer. A review of Resident 1’s undated Kardex indicated for the care providers to utilize assistive devices as needed and to use a mechanical lift during transfers to provide a safe transfer. A review of Resident 1’s Change in Condition (COC) Evaluation, dated 10/18/2023, and timed at 8:45 p.m., the COC indicated, at 8:40 p.m., (10/18/2023) a Certified Nurse Assistant (CNA 1) reported that Resident 1 had an abrasion with swelling to her left knee. The COC indicated Resident 1’s left knee was noted with a greenish discoloration measuring 13 centimeters ([cm] a unit of measurement) and an abrasion measuring 1.5 cm x 2.0 cm. The COC indicated Registered Nurse Supervisor (RNS) 1 obtained an order from Resident 1’s physician’s Nurse Practitioner (NP) for a stat (immediate) x-ray for Resident 1’s left knee and to apply a topical antibiotic daily for 14 days. A review of Resident 1’s Radiology Results Report, dated 10/18/2023, indicated Resident 1’s left knee had swelling and effusion. During an interview on 11/2/2023, at 3:58 p.m. CNA 3 stated, Resident 1 was previously transferred using a mechanical lift. CNA 3 stated that CNA 1 told her that she (CNA 1) transferred Resident 1 (10/18/2023 around dinner time) to a shower chair with the assistance of CNA 2. CNA 1 thought Resident 1 could stand, so CNA 1 and CNA 2 tried to stand Resident 1 up and Resident 1 slid out of her bed. During an interview on 11/2/2023, at 5:52 p.m., CNA 1 stated CNA 2 asked her for assistance to transfer Resident 1 to a shower chair (10/18/2023). CNA 1 stated she and CNA 2 sat Resident 1 on her bed, then she (CNA 1) and CNA 2 stood on each side of Resident 1 and placed one arm under each of Resident 1’s arms then they (CNA 1 and CNA 2) lifted Resident 1 up. After the lift, Resident 1 slid off the bed. CNA 1 stated she did not recall if Resident 1’s feet or knees touched the floor. CNA 1 stated she and CNA 2 lifted Resident 1 and placed her back in her bed. CNA 1 stated she asked Resident 1 if she was in pain and Resident 1 stated “no.” CNA 1 stated, at 7 p.m., when she tried to turn Resident 1 to her side in order to change her adult brief, Resident 1 complained of pain to her left knee. CNA 1 stated she informed the charge nurse (LVN 1) of Resident 1’s complaints of pain. Following LVN 1’s report to RNS 1 an x-ray was ordered. CNA 1 stated residents are not normally mobilized out of bed on evening shift, so she did not check the Activities of Daily Living ([ADL] task such as eating, bathing, dressing, grooming and toileting) sheet to see how Resident 1 should have been transferred. CNA 1 stated it was important to know how Resident 1 should be transferred so Resident 1 would not be injured or fall. During an interview on 11/3/23, at 1:45 p.m., LVN 1 stated CNA 3 notified LVN 1 that she (CNA 3) noticed swelling and discoloration on Resident 1’s left knee (10/18/2023). LVN 1 stated she checked on Resident 1. Resident 1 told LVN 1 that she (Resident 1) slid down the bed when she was transferred from her bed to a shower chair around 5 p.m., (10/18/2023) and bumped both of her knees on the floor causing pain to her left knee. LVN 1 stated, she assessed Resident 1, administered pain medication, and informed RNS 1 of Resident 1’s symptoms of pain. LVN 1 stated Resident 1 was unable to bend her left leg and the care plan required staff to use a mechanical lift to transfer Resident 1 . During an interview on 11/8/2023, at 11:10 a.m., the Director of Rehab (DR) stated, Resident 1 was dependent and required a mechanical lift for transfers. The DR stated staff should use a mechanical lift to transfer Resident 1 from her bed to a chair or a shower chair so Resident 1 would not fall or injure herself. The DR stated Physical Therapists are skilled and trained to perform safe two person transfers from a bed to a wheelchair. The DR stated nursing did not receive that type of training. During an interview on 11/8/2023, at 11:57 a.m., the Director of Staff Development (DSD) stated CNAs should know how a resident should be transferred because the information regarding transfers is located on the Resident’s Kardex and plan of care. The DSD stated if CNAs have a question, they should ask the charge nurse or RNS for clarification regarding how the resident should be transferred. The DSD stated if a resident cannot stand, pivot, or bear weight on their leg(s) a mechanical lift should be used. The CNAs should not lift a resident by placing their arms underneath the resident’s arms because the CNAs could injure the resident, pull a joint out of the Resident’s socket, or the transfer could contribute to a fall. During an interview on 11/21/2023 at 3 p.m., the Treatment Nurse (LVN 2), stated Resident 1 did not have any discoloration to her knees prior to her fall (10/18/2023). LVN 2 stated Resident 1 has pain in her knees all the time and Voltaren cream (a gel/cream used to treat pain) is applied to her knees, which causes her skin to become dry and scaley, however at her baseline Resident 1 had no discoloration to her knees bilaterally. LVN 2 stated she saw the discoloration to Resident 1’s bilateral knees two days after it was documented, and Resident 1 told her she (Resident 1) fell when she was transferred from her bed to a shower chair. During an interview and record review on 11/21/2023, at 4:11 p.m., with the Senior Nurse Executive, the facility’s P/P, titled, “Safe Lifting and Movement of Residents” dated 7/2017, was reviewed. The P/P indicated manual lifting of residents shall be eliminated when feasible. The Senior Nurse Executive stated, when “feasible” is when the resident is not safe to be transferred based upon the resident’s functional status. The Senior Nurse Executive stated the two CNAs (CNA 1 and CNA 2) should have used a mechanical lift when transferring Resident 1 based on Resident 1’s functional status and the information provided to the CNAs on the Kardex. The Senior Nurse Executive stated the CNAs should have accessed the Point of Care (a system that provides the ability for clinicians to document patient finding and assessments, as well as plans of care) Kardex to determine how Resident 1 was to be transferred. During an interview on 11/21/2023, at 5:07 p.m., the Unit Director of Nursing (UDON), stated Resident 1 was being transferred using a mechanical lift prior to her fall to ensure the safety of Resident 1. During an interview on 11/22/2023 at 5:42 p.m., the Clinical Director (CN) stated the Kardex is a clinical tool used by the CNAs to consult and decide how residents should be transferred. The CN also stated the CNAs are taught to access the Kardex to determine how residents should be cared for with regard to transfers when they are hired to work for the facility. CN further stated consulting the Kardex is part of the CNAs’ orientation. A review of the facility’s P/P titled, “Safe Lifting and Movement of Residents,” dated 7/2017, indicated that in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents’ needs for transfer assistance on an ongoing basis. The facility failed to: 1. Ensure Resident 1, who could not bear weight on her left leg, was transferred using a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone), as specified in Resident 1’s care plan and on Resident 1’s nursing assessment and Kardex (a communication tool used to relate important care information regarding residents’ care needs such as assistance with transferring). 2. Ensure the nursing staff followed their policy and procedure (P/P), titled, “Safe Lifting and Movement of Residents,” which indicated, in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. As a result, CNA 1 and CNA 2 attempted to transfer Resident from her bed to a wheelchair by physically lifting her from underneath her arms. During the transfer, CNA 1, and CNA 2 lost control of Resident 1, resulting in Resident 1 sliding from her bed and landing on the floor on her knees. Resident 1 was found with swelling, bruising, and an abrasion (a scrape) to her left knee and was subsequently assessed with swelling and effusion (a buildup of fluid inside of the joint such as a swollen ankle or knee) to her left knee with an order to apply a topical antibiotic to her left knee abrasion for 14 days. 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.