Other·October 25, 2022

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. 22 CCR § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 9/14/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident and a complaint about quality of care and treatment. The facility failed to ensure Resident 1 was free from accident hazards by: 1. Failing to remove the landing mat prior to transferring Resident 1 from the geriatric chair (also known as a geri chair or medical recliner, a large, padded, comfortable reclining chair that allows to sit comfortably while being fully supported and transported to adjoining areas within a facility) to bed. 2. Failing to ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 communicated and worked in sequence with each other while transferring Resident 1 from the geri chair to bed. As a result, Resident 1 sustained a fall on 9/9/2022 requiring transfer to General Acute Care Hospital 1 (GACH 1) where the resident was diagnosed with a right subdural hematoma (serious condition where blood collects between the skull and the surface of the brain) in the frontal and parieto-occipital regions (situated between the parietal and occipital [at the side and back of the skull] bones or lobes), fracture (partial or complete break in the bone) of the right 10th and 11th ribs, and a scalp laceration (wound that is produced by the tearing of soft body tissue) to the back of the head. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 8/28/2017 with diagnosis including Alzheimer’s disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), anemia (blood has a lower-than-normal number of red blood cells), and long-term use of anticoagulants (blood thinners). A review of Resident 1’s Minimum Data Sheet (MDS – a standardized assessment and care-screening tool) dated 6/7/2022 indicated the resident sometimes made self-understood and sometimes could understand others. Resident 1 required two-person physical assistance with bed mobility, transfer, and toilet use. A review of Resident 1’s Quarterly Fall Risk Assessment dated 6/6/22, indicated Resident 1 was a high fall risk. A review of Resident 1’s Care Plan for risk for falls/injury, initiated on 9/3/2022, indicated a goal to reduce risk of falls and injury daily. The care plan interventions included providing Resident 1 with a safe and clutter-free environment. A review of Resident 1’s Change of Condition (COC) Assessment Form dated 9/9/2022 indicated, Resident 1 was transferred from a geri chair to her bed by two (2) CNAs using a Hoyer lift (mechanical lift - a patient lift used by caregivers to safely transfer residents). While trying to reposition the Hoyer lift close to the mattress, the wheels of the Hoyer lift got caught in the landing mat. Resident 1 was moving in the sling supported by another CNA but accidentally slid out from the sling and was assisted by the CNA to the landing mat. Resident 1 was immediately assessed by a licensed nurse with no complaints of pain or discomfort. Resident 1 was able to move upper and lower extremities without difficulty. A skin tear was observed on the back of the head with minimal bleeding. A neurological check (assessment to determine whether the nervous system is impaired) was done with no changes in mental status. The nurse applied a pressure dressing to the cut on the back of the head. Pain medication was given to Resident 1 as a prophylactic (preventive) treatment. Resident 1’s Physician (MD) was notified and ordered to transfer Resident 1 to GACH 1 via non-emergency ambulance for further evaluation and treatment. The COC Assessment Form indicated a skin tear on the back of the head measuring 1centimeter (cm - a unit of measurement) in length by 1cm in length. A review of Resident 1’s General Acute Care Hospital 1 (GACH 1) History and Physical dated 9/10/2022, indicated the following assessment: - Status post (after) fall with blunt head trauma (severe injury to the head). - Right subdural hematoma in the frontal as well as parieto-occipital regions, maximal thickness 8 millimeters (mm - unit of measurement). - Fracture of right 10th and 11th ribs. - Scalp laceration, 1 inch long. During an interview on 9/14/2022 at 12:39 p.m., the Director Nursing (DON) stated on 9/9/2022, CNAs 1 and 2 used a mechanical lift to transfer Resident 1 from the geri chair to her bed. The DON stated during the transfer, the front part of the mechanical lift got stuck on the landing mat and the sling holding the resident was moving and Resident 1 slid out of the sling. The DON stated Resident 1 hit her head, but the two CNAs were unable to say where Resident 1 hit her head. The DON stated Resident 1 had a skin tear on the back of her head. The DON stated Resident 1 was transferred to the hospital and was told by Resident 1’s daughter the resident had two rib fractures. During an interview on 9/14/2022 at 3:17 p.m., the Director of Staff Development (DSD) stated she did an immediate in-service for CNA 1 and CNA 2. The DSD stated she did a skills checklist with each CNA for the use of the mechanical lift and discussed with the two CNAs about decluttering of the room. The DSD stated she asked CNA 1 and CNA 2 what happened and was told that when Resident 1 was being transferred back to her bed, CNA 1 moved the mechanical lift forward towards the bed and the wheels got stuck on the landing mat causing the sling to move around and Resident 1 slid off the sling. The DSD stated the CNAs told her it happened so fast, CNA 1 and CNA 2 were unable to say where Resident 1 hit her head. The DSD stated Resident 1 slid off, but CNA 2 was holding onto the resident’s legs when the resident’s head went first. The DSD stated common factors for a mechanical lift getting stuck on something could be landing mats and electrical cords. The DSD stated that in-service training covered these ways in which a mechanical lift might get stuck. The DSD stated there’s a risk the mechanical lift could meet resistance with the landing mat. The DSD stated moving forward, she has instructed all staff to remove landing mats before mechanical lift transfers because of this incident. During an interview on 9/16/2022 at 3:38 p.m., CNA 1 stated she was not taking care of Resident 1 but helped CNA 2 with transferring Resident 1 back to her bed from the geri chair. CNA 1 stated she used a mechanical lift to lift Resident 1 from the geri chair and when she pushed the mechanical lift towards the bed, the front wheels of the mechanical lift got stuck on the landing mat. CNA 1 stated she doesn’t remember if Resident 1 fell out of the sling feet first or headfirst, but she suddenly fell, and the sling was still connected to the mechanical lift. CNA 1 stated Resident 1 fell on the landing mat and saw bleeding on the back of Resident 1’s head. CNA 1 stated she received an in-service from the DSD right after the incident and was taught to pay attention when using the mechanical lift, using a mechanical lift is always a two-person assist, remove landing mats, and to talk to the other person helping and communicate with each other. CNA 1 stated she has used a mechanical lift many times and stated their process is to always remove the landing mats. CNA 1 stated she doesn’t know what happened that day and she saw there was a landing mat but forgot to take it out. CNA 1 stated she should have taken out the landing mat. During an interview on 9/21/2022 at 3:26 p.m., CNA 2 stated she brought the mechanical lift to the room to transfer Resident 1 from the geri chair back to bed. CNA 2 stated she felt rushed because of another resident and forgot to take out the landing mat. CNA 2 stated it has been the facility’s process to always remove the landing mat during mechanical lift transfers. CNA 2 stated CNA 1 was the one using the mechanical lift and lifted Resident 1 from the geri chair. CNA 2 stated as she was moving the geri chair out of the way, she saw a reflection of the sling moving back and forth. CNA 2 stated CNA 1 had pushed the mechanical lift forward while she was moving the geri chair out of the way. CNA 2 stated she was not back in position when CNA 1 began to move forward with the mechanical lift. CNA 2 stated she saw the sling move back and forth and she caught the resident’s legs when the sling was swinging, and Resident 1 suddenly slid out of the sling and landed on the landing mat. CNA 2 stated it happened so fast she doesn’t remember where Resident 1 hit her head. During a concurrent observation and interview on 9/21/2022 at 3:47 p.m., with CNA 2 and the DSD, CNA 2 demonstrated how the incident had occurred. CNA 2 demonstrated how she removed the geri chair and explained while she was doing that, she saw the sling moving back and forth when CNA 1 had pushed the mechanical lift forward and got stuck on the landing mat. CNA 2 stated she grabbed Resident 1’s legs however the resident had slid from the bottom part of the sling and landed on the landing mat. CNA 2 stated she is not sure where the resident had hit her head. The DSD demonstrated pushing the mechanical lift over the landing mat and observed how front feels met resistance causing the attached sling to move back and forth. During an interview on 9/21/2022 at 4:02 p.m., the DSD stated she taught the CNAs to always be at the head of the resident while they are in the sling and that it would be easier to maneuver the sling due to the strap located on the top back part of the sling. The DSD stated Resident 1’s fall could have been prevented if there was no landing mat. The DSD stated CNA 1 and CNA 2 should have worked in sequence with each other. The DSD stated CNA 1 should have waited for CNA 2 to finish moving the geri chair and then go forward with the mechanical lift together. During an interview on 9/23/2022 at 4:02 p.m., the DON stated CNA 1 should have waited and made sure their partner is ready to assist. The DON stated CNA 1 should not have pushed the mechanical lift until CNA 2 was ready. The DON stated CNA 2 would have been ready to catch the resident in the sling when it started swinging. The DON stated the two CNAs should have communicated with each other. The DON further stated CNA 1 and CNA 2 should have removed the landing mat and kept the room free of clutter. The DON stated removing the landing mat and waiting for CNA 2 to be ready and communicating with each other would have prevented Resident 1 from falling. A review of the in-service education provided to CNA 1 and CNA 2 dated 9/9/2022, indicated the following topic/content: - Policy and procedure of mechanical lift. - Two person assist when utilizing the mechanical lift. - De-cluttering the area prior to using the mechanical lift for prevention of the machine getting stuck (i.e., landing pad, bed cords). - Fall precaution measures. A review of the facility’s policy and procedure titled, “Mechanical Lifts,” undated, indicated, “This facility is a non-lift facility, so mechanical lifts will be used for transferring resident who cannot assist the transfers. A two-person assist is required when using a lift.” The policy did not include that nursing was to ensure the area of transfer was free from clutter for safe use of the lift. A review of the facility’s policy and procedure titled, “Avoidance of Environmental Hazards,” undated, indicated, “This facility will strive to provide a hazard-free environment to ensure that the residents safety is maintained…The Direct Care Givers (CNAs) will randomly check the resident’s unit, with the resident’s permission, to identify and/or remove items that may present a risk to the resident’s safety.” The facility failed to ensure Resident 1 was free from accident hazards by: 1. Failing to remove the landing mat prior to transferring Resident 1 from the geriatric chair to bed. 2. Failing to ensure CNA 1 and CNA 2 communicated and worked in sequence with each other while transferring Resident 1 from the geri chair to bed. As a result, Resident 1 sustained a fall on 9/9/2022 requiring transfer to GACH 1 where the resident was diagnosed with a right subdural hematoma in the frontal and parieto-occipital regions, fracture of the right 10th and 11th ribs, and a scalp laceration to the back of the head. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.