Other·May 11, 2023

42 CFR § 483.21(b) Comprehensive Care Plans (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality. 42 CFR § 483.25(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 3/24/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint. The facility failed to ensure Resident 1’s environment was free from accident hazards and the resident received services that met professional standards of nursing of practice, by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) used the correct size of sling (used an extra-large instead of a medium) with Resident 1 to transfer the resident using a lift machine (designed to lift and transfer patients from one place to another and may be operated using a power source or manually; lift machines use a lifting sling [soft fabric tool that wrap around a patient's body] hooked to the lift; sling lifts come in various sizes, materials, and weight capacities) on 3/1/2023. 2. Ensure CNA 2 accurately reported to Licensed Vocational Nurse 1 (LVN 1) that when helping CNA 1 transfer Resident 1 from chair to bed using the lift machine on 3/1/2023, between 9:30 a.m. and 10 a.m. the resident slipped out of the sling and CNA 2 held the residents legs but did not remember if the resident’s body (trunk: chest, abdomen, hip, and back) hit the floor rather than CNA 2 telling LVN 1 that CNA 2 was able to catch the resident to prevent Resident 1 from hitting the floor, as CNA 2 told the Evaluator. 3. Ensure LVN 1, after learning about Resident 1 slipping out of the sling, immediately went to check on Resident 1 and inform the on-duty Registered Nurse (RN) supervisor for a complete assessment (head-to-toe) of Resident 1 to rule out any injury. 4. Start an investigation on 3/1/2023, after learning about Resident 1 slipping out of the lift sling, to determine the circumstances of the incident to identify causal factors and verify the report LVN 1 initially received, as well as determine if Resident 1 sustained injuries and if staff were competent to use the lift safely. 5. Monitor Resident 1 during the remainder of the 7 a.m. to 3 p.m. shift on 3/1/2023, for any injuries. 6. Document Resident 1’s fall incident reported to LVN 1 on 3/1/2023, around 10 a.m. and initiate a Change of Condition form as per facility’s policy. 7. Report Resident 1’s morning incident of slipping out of the lift sling on 3/1/2023, to the incoming shift (3 p.m. to 11 p.m.) to monitor Resident 1 for any possible delayed injuries. As a result, on 3/3/2023 (two days after the fall), Resident 1’s oxygen saturation (oxygen in the blood) became low and the resident was mumbling (no longer able to speak clearly), requiring emergent transfer to general acute care hospital 1 (GACH 1). GACH 1 determined Resident 1 had a right hip fracture on the same day. On 3/5/2023, Resident 1 underwent surgery to repair the fracture. A review of Resident 1’s Admission Record indicated the facility originally admitted the resident, a 79-year-old male, on 10/5/2020 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), repeated falls, and benign prostatic hyperplasia (BPH, enlarged prostate [gland in the male reproductive system] that may cause problems associated with urination). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/23/2023, indicated the resident had memory problems, could understand others, and could make herself understood. Resident 1 required extensive assistance with bed mobility and was totally dependent on staff with transfers, requiring two or more-person physical assist. The MDS indicated the resident was not steady and could only stabilize with staff assistance during surface-to-surface transfer (between bed and chair). Resident 1’s weight was 127 pounds. A review of Resident 1’s nursing Progress Notes, indicated there was no documentation dated 3/1/2023 about the resident’s incident of slipping out of the lift machine. A review of Resident 1’s SBAR (Situation, Background, Assessment, and Recommendation, a tool to aid in facilitating and strengthening communication between health care staff) Communication form, documented by LVN 1 on 3/2/2023 (late entry), indicated receiving a report on 3/1/2023, that Resident 1 slipped out of the sling during transfer. CNA 2 caught Resident 1 before hitting the floor. Upon assessment, the resident had redness to the right side on the scalp. Resident 1 had no complaints of pain. The SBAR indicated LVN 1 notified the resident’s caregiver and the attending physician on 3/2/2023 at 11 a.m. The physician ordered an x-ray of the skull. The x-ray result was negative for a fracture. No other injuries were identified. The SBAR indicated Resident 1 would be monitored for any delayed sign of injuries. A review of Resident 1' s SBAR Communication form, dated 3/3/2023, indicated at 1:32 p.m., the resident had oxygen desaturation (low oxygen in the blood), with the resident’s oxygen saturation reading at 86% (normal above 95%) and the resident was mumbling. Resident 1 was speaking but not in his baseline. Staff gave Resident 1 oxygen at 2 liters per minute (2 L/min) via nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). The licensed nurse documented calling Emergency Medical Services (EMS, paramedics) and the paramedics transferred Resident 1 to GACH 1. A review of Resident 1’s GACH 1 History and Physical Reports dated 3/4/2023, indicated the GACH 1 staff noted resident had pain upon transfer onto the gurney. GACH 1 staff initiated an extensive work-up in the emergency room (3/3/2023) and GACH 1 staff noted the resident had a right hip fracture. A review of Resident 1’s GACH 1 Computed Tomography (CT, a diagnostic test that produces images of the inside of the body), dated 3/3/2023, indicated a suspected right femoral (thigh bone) neck fracture for the resident. A review of Resident 1’s GACH 1 Discharge Instructions, dated 3/7/2023, indicated Resident 1 underwent a hemiarthroplasty (partial hip replacement, leaving the socket intact and replacing only the thigh side of the bone) of the right hip on 3/5/2023. Resident 1 was transferred back to the facility on 3/7/2023. During an interview on 3/24/2023 at 10:29 a.m., CNA 1 stated she was the assigned CNA to Resident 1 on 3/1/2023 when the fall incident happened. CNA 1 stated after she assisted Resident 1 with a shower, she and CNA 2 were transferring Resident 1 back to bed. CNA 1 stated she was the one managing the lift machine and CNA 2 assisted her with the transfer. CNA 1 stated during the transfer one of the sling hooks came loose from the lift machine and the resident slipped out of the sling. CNA 2 caught the resident and was able to put the resident back to bed. CNA 1 stated she saw the resident hit his head on the bed’s foot board. CNA 1 stated the resident had been itchy and was wiggling in the air and one of the slings became unhooked. On 3/24/2023 at 11:15 a.m., during an interview, LVN 1 stated on 3/1/2023, CNAs 1 and 2 informed him Resident 1 slipped from the sling but one of them caught the resident preventing him from hitting the floor. LVN 1 stated he checked the resident and asked him if he had any pain and did not see anything on the resident’s head. LVN 1 stated the resident did not hit the floor and if the resident had hit the floor, LVN 1 would have notified the resident’s attending physician and the resident’s responsible party. LVN 1 stated he did not talk to his supervisor until the next day. LVN 1 stated he did not document a change in condition for the resident because the resident did not fall and hit the floor. On 3/24/2023 at 1:13 p.m., during a concurrent observation of the lift use and interview, CNA 1 brought a sling similar to the one used in transferring Resident 1 and stated the slings came only in one size. CNA 1 was unaware the slings had different sizes based on the resident’s weight and size, despite attending in-services on fall precautions and lift transfers and sling placement. On 3/24/2023 at 1:22 p.m., during a concurrent observation and interview, CNA 1 and CNA 2 did a demonstration of the transfer of Resident 1 in the Rehab Room using a dummy, a sling, and a lift machine. CNA 2 stated the slings size go from small, medium, large, and extra-large. CNA 2 stated small should be used for Resident 1 but an extra-large was used. During an interview on 3/24/2023 at 2:22 p.m., the Assistant Director of Nursing (ADON) stated on 3/2/2023 during the standup meeting (consists of nursing going over the 24-hour report, incidents, follow ups, etc.) she learned about Resident 1’s incident. The ADON stated LVN 1 should have done a change of condition assessment and monitoring right away on 3/1/2023 and should have notified the resident’s attending physician and responsible party right away. On 3/24/2023 at 2:39 p.m., during a concurrent observation of the slings and interview, the Director of Staff Development (DSD) stated the size of the sling used depends on the positioning of the resident. The DSD stated the red, blue, green, and black go small, medium, large, extra-large respectively. The DSD stated this is determined by making sure the sling fits snug to the resident. On 3/24/2023 at 3:11 p.m., during an interview, the DON stated all CNAs are trained for the proper use of the sling for resident safety but did not provide documented evidence of staff demonstration or that the DSD observed how the CNAs were using the lifts with the sling. The DON was unable to provide evidence of a thorough investigation of the potential causes of Resident 1’s fall to prevent further falls of Resident 1 and other residents using lift machines. A review of the facility’s policy and procedure titled, “Total Mechanical Lift,” revised on 4/22/2022, indicated nursing staff will be trained to use the mechanical lift. The procedure indicated to hook the loops on the side of u-sling to sling bar and attach each corner of the sling to the correct hook on the sling bar. A review of the facility’s policy and procedure titled, “Change of Condition Notification,” revised on 4/22/2022, indicated that the facility will promptly inform the resident, consult with the resident’s attending physician, and notify the resident’s legal representative when the resident endures a significant change in condition caused by, but not limited to an injury or accident. The procedure indicated the attending physician will be notified timely with a resident’s change in condition The procedure further indicated that the licensed nurse would notify the resident, the resident’s responsible party, or the family or surrogate decision-makers of any changes in the resident’s condition as soon as possible. The facility failed to ensure Resident 1’s environment was free from accident hazards and the resident received services that met professional standards of nursing of practice, by failing to: 1. Ensure CNA 1 used the correct size of sling with Resident 1 to transfer the resident using a lift machine on 3/1/2023. 2. Ensure CNA 2 accurately reported to LVN 1 that when helping CNA 1 transfer Resident 1 from chair to bed using the lift machine on 3/1/2023, between 9:30 a.m. and 10 a.m. the resident slipped out of the sling and CNA 2 held the residents legs but did not remember if the resident’s body hit the floor rather than CNA 2 telling LVN 1 that CNA 2 was able to catch the resident to prevent Resident 1 from hitting the floor, as CNA 2 told the Evaluator. 3. Ensure LVN 1, after learning about Resident 1 slipping out of the sling, immediately went to check on Resident 1 and inform the on-duty RN supervisor for a complete assessment of Resident 1 to rule out any injury. 4. Start an investigation on 3/1/2023, after learning about Resident 1 slipping out of the lift sling, to determine the circumstances of the incident to identify causal factors and verify the report LVN 1 initially received, as well as determine if Resident 1 sustained injuries and if staff were competent to use the lift safely. 5. Monitor Resident 1 during the remainder of the 7 a.m. to 3 p.m. shift on 3/1/2023, for any injuries. 6. Document Resident 1’s fall incident reported to LVN 1 on 3/1/2023, around 10 a.m. and initiate a Change of Condition form as per facility’s policy. 7. Report Resident 1’s morning incident of slipping out of the lift sling on 3/1/2023, to the incoming shift (3 p.m. to 11 p.m.) to monitor Resident 1 for any possible delayed injuries. As a result, on 3/3/2023 (two days after the fall), Resident 1’s oxygen saturation became low and the resident was mumbling, requiring emergent transfer to GACH 1. GACH 1 determined Resident 1 had a right hip fracture on the same day. On 3/5/2023, Resident 1 underwent surgery to repair the fracture. 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 to Resident 1.