Other·August 26, 2022

42 CFR §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. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 3/29/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint and facility-reported incident investigation about an injury of unknown origin. The facility failed to ensure Resident 1 was provided a safe environment and assistance to prevent accidents and injury by not having two staff assisting Resident 1, who had functional quadriplegia (partial or complete paralysis [inability to move] from the neck down including both arms and legs), with transfers to and from bed as per facility’s policies. As a result of the improper transfer, Resident 1 sustained a dislocated shoulder (injury in which the upper arm bone comes out of the shoulder blade socket). A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 51-year-old female, on 1/29/2022 with diagnoses including amyotrophic lateral sclerosis (ALS, commonly known as Lou Gehrig’s disease, a progressive neuromuscular degeneration of motor nerve cells in the brain and spinal cord), chronic respiratory failure, muscle wasting and atrophy (a condition caused by disuse of the muscles or neurogenic condition), and functional quadriplegia. A review of Resident 1’s Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 2/5/2022, indicated the resident had the ability to communicate needs and understand others. Resident 1 was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 1 did not walk and did not use a wheelchair or other mobility device (bedbound). Resident 1 needed two or more staff assistance with transfers. Resident 1 was continent (able to control) of bowel and bladder functions. A review of Resident 1’s Care Plan developed on admission and revised on 2/8/2022 for the resident’s Self-Care Deficit with activities of daily living (ADLs, such as bed mobility, personal hygiene, transfers, toilet use, and bathing) indicated in the interventions to provide Resident 1 with the assistance needed. The care plan did not indicate how staff were to transfer the resident (manually or with the use of a transferring device/equipment) and how many staff were required for transferring. A review of Resident 1’s Care Plan developed on admission and revised on 2/8/2022 for the resident’s Risk for Falls and injuries, had a goal to reduce the resident’s risks for falls and injuries. The interventions included providing safety measures (not specified) and frequent supervision and monitoring. A review of Resident 1’s ADLs documentation by Certified Nursing Assistants (CNAs) from 3/1/2022 to 3/18/2022, indicated the resident required either the support of one or two staff. For the 7 a.m. to 3 p.m. shift, the CNAs documented Resident 1 was assisted with transfers by two persons on five days and by one person on 12 days, Resident 1 was assisted with transfers by two persons on nine days and by one person on seven days. For the 11 p.m. to 7 a.m., the activity did not occur. A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR, a communication technique to facilitate prompt communication between the health care team member), dated 3/18/2022 at 2:15 p.m. indicated CNA 1 called for the licensed nurse’s attention to Resident 1’s room and the resident’s right shoulder had a bony protrusion (bone bulges out or sticks out) and Resident 1 complained of right shoulder pain rated 7 out of 10 (7/10, rating pain scale from zero to 10, zero indicating no pain and 10 the most excruciating pain). The licensed nurse notified the attending physician and ordered X-rays (radiation called electromagnetic waves which create pictures of the inside of the body) of the right shoulder. A review of Resident 1’s Radiology (X-rays) Results Report dated 3/18/2022 indicated in the humerus (the long bone of the upper arm) was anteriorly (front) and inferiorly (lower) dislocated with respect to the glenoid (the end of the scapula [shoulder blade]). There was no fracture but anterior shoulder dislocation (the ball and socket bones of the shoulder are separated on the front). On 3/29/2022 at 12:15 p.m., an interview with Resident 1 was conducted with the resident using a communication device (for individuals who are unable to communicate reliably with their own voices due to language and physical impairments). Resident 1 stated that on 3/18/2022 at 2:20 p.m. CNA 1 transferred her (manually) to a shower chair (a seat made for bathtubs, showers and over the toilet designed for use by people who are unable to stand to take a shower and must sit instead) when she asked to go to the restroom. When CNA 1 lifted her from bed, “I heard a popping sound from my shoulder but as you see me, I can’t speak. I wanted to tell him, but he didn’t see me. I was in tears, and he noticed I was crying. My shoulder was hurting.” Resident 1 stated two staff were supposed to transfer her, but CNA 1 did it alone. Resident 1 stated she did not want to be transferred using a lift machine but manually. On 3/29/2022 at 12:48 p.m., during an interview, CNA 1 stated on 3/18/2022, around 2:30 p.m., Resident 1 called for assistance to go to the restroom, and he transferred Resident 1 to a shower chair by himself. CNA 1 stated he placed his arms underneath the resident’s armpits and transferred her to the shower chair. CNA 1 noticed Resident 1 crying and asked if she was in pain and Resident 1 nodded. CNA 1 stated he transferred Resident 1 back to the bed and called the charge nurse. CNA 1 stated he was aware two staff were needed to transfer the resident. On 3/29/2022 at 1:15 p.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent record review, the ADON stated Resident 1 declined to get transferred to a hospital for further evaluation on 3/18/2022 and agreed to see an orthopedist (is a medical specialty focusing on injuries and diseases affecting the bones, muscles, joints, and soft tissues). Resident 1 visited an orthopedic doctor on 3/23/2022 who said Resident 1 was not a good candidate for surgery. The ADON confirmed the MDS indicated Resident 1 needed two-person assist for transfers but the care plan for ADLs deficit did not include the need of two-person assist and the technique staff was to use when manually transferring the resident. On 04/05/2022 at 12:54 p.m., during a telephone interview, Physical Therapist 1 (PT 1) stated Resident 1 required two-person assistance for transfer. A review of the undated facility’s policy and procedure titled, “Avoidance of Environmental Hazards” indicated the facility will strive to provide a hazard-free environment to ensure that resident’s safety is maintained. A review of the undated facility’s policy and procedure titled, “Accident/Incident Prevention” indicated that the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents and incidents, and providing adequate care plans with procedures to prevent accidents. A review of the facility’s policy and procedure titled, “The Resident Care Plan”, undated, indicated that the facility will provide an individualized nursing care plan and promote continuity of resident care. The policy and procedure further indicated that the care necessitated by the resident’s individual needs should be recorded. The facility failed to ensure Resident 1 were provided a safe environment and assistance to prevent accidents and injury by not having two staff assisting Resident 1, who had functional quadriplegia, with transfers to and from bed. As a result of the improper transfer, Resident 1 sustained a dislocated shoulder. The above 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 Resident 1.