Health inspection·January 25, 2024

42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. 42 CFR §483.25: Free of Accident Hazards/Supervision/Devices §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 11/17/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. The facility failed to ensure Resident 2, who was dependent on staff for transfers and was a fall risk, was provided a safe environment and assistance to prevent accidents and injury. On 11/21/2023 at around 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3 manually transferred Resident 2 instead of using the mechanical device assessed as needed by Resident 2 (a Hoyer lift, a type of assistive medical device used to transfer residents who need support, by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back). The facility failed to implement Resident 2’s care plan intervention to use the mechanical lift during transfers. In addition, the facility failed to comply with its own established policies and procedures (P&P) on Resident Lifting / Assisting Transfer, Mechanical Lifts, and Accident/ Incident Prevention. As a result, when CNAs 2 and 3 stood Resident 2 up prior to seating her in the shower chair (a sturdy seat designed for individuals who need support while bathing), Resident 2 was injured, and cried out loud complaining of pain on the right knee area. The same day, 11/21/2023, x-rays (electromagnetic images of internal tissues, bones, and/or organs) showed Resident 2 had mildly comminuted fracture (break of a bone in at least two places) of the distal (bottom of the bone, by the knee) femoral (thigh bone) shaft (top part of the knee joint). On the same day, 11/21/2023, Resident 2 was transferred to General Acute Care Hospital 1 (GACH 1) where, the following day, 11/22/2023, Resident 2 underwent open reduction and internal fixation (ORIF, a surgical procedure that involves putting pieces of bone into place using screws or rods to hold the broken bone together) of the right femur fracture. A review of Resident 2’s Admission Record indicated the facility admitted the resident, a 96-year-old female, on 1/28/2023 with diagnoses including diastolic congestive heart failure (the left side of the heart become stiffer than normal causing the heart not pumping enough blood to the body), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 2’s History and Physical exam, dated 1/30/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 2’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 2 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), was dependent to staff for toileting hygiene, shower, and transfer to and from a bed to a chair (or wheelchair). A review of Resident 2’s Occupational Therapist Evaluation and Plan of Treatment dated 1/30/2023 to 2/26/2023 indicated resident was dependent on staff for transfers and needed the use of a Hoyer lift as transfer assistive device. A review of Resident 2’s Care Plan developed on 3/16/2023 and revised on 11/10/2023, indicated the need of two-person assistance using the lift machine for safety. A review of Resident 2’s Change of Condition (COC) Interact Assessment Form, dated 11/21/2023 at 10 a.m., indicated that CNAs 2 and CNA 3 were going to transfer Resident 2 to the shower chair, when Resident 2 complained of pain. CNAs 2 and 3 put Resident 2 back to bed. The COC form indicated Registered Nurse 1 (RN 1) heard Resident 2 crying in pain and upon assessment noted the right thigh swollen and pain with movement of the leg. RN 1 notified the physician who ordered stat (urgent) x-rays. The COC form indicated Physical Therapist 1 (PT 1) applied a long brace immobilizer (a plastic shell that wraps around the knee and is often attached to a leg strap to prevent movement) on Resident 2’s right leg. The COC form indicated that at 12:56 p.m., the x-rays result showed a right femur fracture. The COC form indicated that at 12:58 p.m., the physician ordered to transfer Resident 2 to GACH 1. Resident 2 was picked up at 2 p.m. by ambulance. A review of Resident 2’s Patient Report (right knee x-rays results), dated 11/21/2023, indicated an acute (recent onset) or subacute (it has begun to heal) fracture of the distal femoral shaft. During an interview on 11/22/2023 at 9:46 a.m., CNA 2 stated that on 11/21/2023 at 7 a.m., she saw Resident 2 asleep on low-position bed. CNA 2 called CNA 3, who was passing by the hallway, and asked her assistance to help her transfer Resident 2 from the bed to the shower chair. They both assisted Resident 2 to sit at the edge of the bed and CNA 3 applied the gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing) and on Resident 2’s waist. CNA 2 stood on Resident 2’s left side and CNA 3 stood on the right side. They both placed their arm under Resident 2’s armpits while holding on the gait belt from Resident 2’s back. When they stood Resident 2 up, the resident cried out. They put Resident 2 down to the bed on a sitting position and called for help. Resident 2 had been in the facility for almost a year and was always transferred with two-person assist without using a lift machine. CNA 2 stated she was not informed to use a Hoyer lift when transferring Resident 2. During an interview on 11/22/2023 at 10:01 a.m., CNA 3 stated on 11/21/2023 CNA 2 called her when she was walking in the hallway passing by Resident 2’s room at around 9:45 a.m. CNA 3 reiterated the same information from CNA 2’s statement on the procedure used in transferring Resident 2. CNA 3 confirmed Resident 2 was not in pain before the attempt to move her. They were able to stand Resident 2 and when they were about to pivot her to sit on the shower chair Resident 2 screamed in pain. Registered Nurse 1 (RN 1) came right away inside the room. During an interview on 11/22/2023 at 10:08 a.m., RN 1 stated she was in the nurse’s station when she heard Resident 2 crying out. RN 1 entered Resident 2’s room, where she (RN 1) saw Resident 2 lying in bed holding her right upper thigh with CNA 2 and CNA 3 standing by Resident 2 bedside. RN 1, upon assessment, noticed swelling on residents right upper thigh. RN 1 applied ice pack, called the doctor and PT 1 came to apply lidocaine (a medication used to numb a specific area of tissue) ointment and right leg immobilizer. During an interview on 11/22/2023 at 10:25 a.m., the Director of Rehabilitation (DOR) stated on 1/2023 upon initial screening, Resident 2 was very weak, and she (the DOR) recommended the use of Hoyer lift. During a concurrent interview and record review on 11/22/2023 at 10:38 a.m., with PT 1, Resident 2’s Care Plan on at risk for fall, dated 3/16/2023 and revised on 11/10/2023, was reviewed. The Care Plan indicated as an intervention that transfers should be completed via two-person assist using a Hoyer lift transfer for safety. PT 1 stated nursing staff should follow the care plan and use the Hoyer lift for safe transfer according to the care plan. PT 1 stated Hoyer lift is used to transfer residents and prevent injury to residents and staff. PT 1 stated if CNA 2 and CNA 3 had used the Hoyer lift the fracture could have been avoided. During a concurrent interview and record review on 11/22/2023 at 10:56 a.m., with the Director of Nursing (DON), Resident 2’s Care Plan on at risk for fall, dated 3/16/2023 and revised on 11/10/2023, was reviewed. The DON stated the care plan indicated the use of two person and a Hoyer lift for transfer. The DON stated CNAs 2 and 3 should have followed the care plan on the use of Hoyer lift to prevent fall and injury. A review of Resident 2’s GACH 1 Skilled Nursing Facility Transfers Orders form, dated 11/23/2023, indicated resident had an ORIF of the right femur fracture on 11/22/2023. A review of facility’s P&P titled, “Resident Lifting, Assisting Transfer Policy,” reviewed on 9/29/2023, indicated, “No resident lift or assisted transfers will be attempted without using either a Vander lift (brand name of a battery-operated lift that helps transfer residents with minimal effort), an Invacare lift (brand name of a lift that makes handling transfer situations safer and more affordable) or a Hoyer lift except as detailed below: Use of mechanical lift requires at least two persons. The Charge Nurse is responsible for identifying those residents that require the use of a lift that will be identified on the care plan and the activities of daily living (ADL) sheet.” A review of facility’s P&P titled, “Mechanical Lifts,” reviewed on 9/29/2023, indicated, “This facility is a non-lift facility, so mechanical lifts will be used for transferring resident who cannot assists the transfers. A two-person assist is required when using a lift.” A review of facility’s P&P titled, “Accident/ Incident Prevention,” undated but reviewed on 9/29/2023, indicated, “In order to provide an environment that is free of accident hazards, the facility will: 10. Provide care planning with implementation plans.” The facility failed to ensure Resident 2, who was dependent on staff for transfers and was a fall risk, was provided a safe environment and assistance to prevent accidents and injury. On 11/21/2023 at around 9:45 a.m., CNA 2 and CNA 3 manually transferred Resident 2 instead of using the mechanical device assessed as needed by Resident 2. The facility failed to implement Resident 2’s care plan intervention to use the mechanical lift during transfers. In addition, the facility failed to comply with its own established P&P on Resident Lifting / Assisting Transfer, Mechanical Lifts, and Accident/ Incident Prevention. As a result, when CNAs 2 and 3 stood Resident 2 up prior to seating her in the shower chair, Resident 2 suffered a comminuted fracture of the distal femoral shaft, requiring transfer to a GACH and ORIF surgery. 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 2.