Other·November 9, 2023

42 CFR § 483.21 (b) Comprehensive Care Plans (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; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally competent and trauma-informed. 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 § 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. On 9/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility for a Recertification Survey and reviewed Resident 27’s quality of care received at the facility. The facility failed to provide Resident 27, who was a fall risk and was totally dependent on staff for transfers, a safe environment, and the safe use of an assistance device to prevent accident and injuries as indicated on the comprehensive plan of care. On 6/12/2023, at 6:20 p.m. Certified Nursing Assistant 1 (CNA 1) independently transferred Resident 27 using a Hoyer lift (a brand of lift machine (an assistant device that rolls on wheels [metal frame] and is intended to help lift, suspend with a sling, and transfer residents with mobility problems from and to bed. During two-person operation, one person engages the unit's controls while the other person handles and guides the individual being transferred)). As a result of the one-person transfer, Resident 27 fell and sustained a head injury and a scalp laceration (cut) requiring a transfer to General Acute Care Hospital 1 (GACH 1), where Resident 27 received six staples to the scalp laceration. A review of Resident 27’s Admission Record indicated the facility admitted the 87-year old female resident on 1/6/2021 and readmitted on 11/25/2022 with diagnoses including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to the entire body]), and long term (current) use of anticoagulants (a group of medications that decrease the blood's ability to clot). A review of Resident 27’s Care Plan, developed on 12/1/2022 for the resident’s activity of daily living (ADLs), indicated resident had self-care performance deficit, was totally dependent for care, and needed to utilize two-staff assistance. The interventions included to encourage the resident to fully participate, allow sufficient time for dressing and undressing, and encourage the resident to use call light to call for assistance. A review of Resident 27’s Care Plan, developed on 12/1/2022 for the resident’s impaired mobility dependent for transfer using a Hoyer lift, indicated interventions including checking skin for breakdown, maintaining a safe environment, and reporting to the physician any incident of fall/injury. A review of Resident 27’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 6/3/2023 indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 27’s Fall Risk Assessment, dated 6/12/2023, indicated the resident did not have history of falls in the past 6 months. The assessment indicated Resident 27’s fall risk score was 8 (medium fall risk, a score above 10 represented high fall risk). A review of Resident 27’s Situational-Background-Assessment-Recommendation (SBAR - a technique to aid in facilitating and strengthening communication between health care staff) form, dated 6/12/2023, documented by Licensed Vocational Nurse 1 (LVN 1) indicated that at 6:20 p.m. LVN 1 heard screams for help from Resident 27’s room and upon arriving to the room found both Resident 27 and CNA 1 sitting on the floor. Resident 1 was identified with an occipital (back part of the skull) laceration measuring 4 centimeters (cm – unit of measurement) in length by 1 cm in width. LVN 1 notified Resident 27’s attending physician, who ordered transferring Resident 27 to GACH 1 for evaluation and treatment. LVN 1 documented CNA 1 stated she (CNA 1) was transferring Resident 27 back to bed using the Hoyer lift and the resident slipped out and sat on the floor, then leaned back and hit her head on the floor. A review of Resident 27’s GACH 1 After Visit Summary Report, dated 6/12/2023, indicated Resident 27 had a head injury, scalp laceration requiring staples. Resident 1 was transferred back to the facility the same day. A review of Resident 27’a Body Check upon re-admission to the facility, dated 6/13/2023, indicated Resident 27 had a laceration to the back of her head with 6 staples. A review of the Physician’s Order for Resident 27, dated 6/13/2023, indicated cleanse scalp laceration with staples with normal saline (a mixture of salt and water), pat dry and leave open to air every shift for 14 days. During an interview on 10/1/2023 at 1:38 p.m., CNA 2 stated she worked the evening of Resident 27’s fall (6/12/2023) but was not involved and did not observe the incident. CNA 2 stated that her supervisors informed her that during transfer of Resident 27 CNA 1 operated the Hoyer lift by herself and Resident 27 fell. During an interview on 10/1/2023 at 1:31 p.m., LVN 2 stated she was with LVN 1, who was the nurse for Resident 27, when they heard someone scream for help. LVN 2 stated she and LVN 1 went to Resident 27’s room and saw CNA 1 holding Resident 27 by the back, they were both on the floor next to the Hoyer lift. Resident 27 had a laceration on her head, and Emergency Medical Services (EMS, paramedics) were called, and Resident 1 was transferred to GACH 1. LVN 2 stated that CNA 1 was alone with Resident 27 and no other staff was in the room. LVN 2 stated when transferring a resident using the Hoyer lift there must be two staff as a safety precaution to ensure the resident does not fall off the lift machine. During an interview on 10/02/2023 at 11:12 a.m., the Director of Nursing (DON) stated CNA 1 broke the facility’s policy when she transferred Resident 27 without assistance of another staff and did not use safe placement of the Hoyer lift sling. The DON stated she reviewed with CNA 1 the procedure on using the sling and the lift and CNA did not use the cross sling (a type of sling) with Resident 27. The DON stated the facility’s policy was to use two-person assistance when using the lift. The DON stated Resident 27’s injury was preventable. The DON stated CNA 1 and LVN 1 were no longer working at the facility. On 10/2/2023 the Evaluator attempted contacting LVN 1 and CNA 1 by telephone but did not get a response. A review of the facility’s policies and procedures titled, “Lifting Machine, Using a Mechanical,” last revised on 2/3/2023, indicate at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A review of the Invacare Hoyer Lift manufacturer’s guidelines indicated it is recommended that two assistants be used for all lifting preparation, transferring from, and transferring to, procedures. The facility failed to provide Resident 27, who was a fall risk and was totally dependent of staff for transfers, a safe environment, and the safe use of an assistance device to prevent accident and injuries as indicated on the comprehensive plan of care. On 6/12/2023, at 6:20 p.m. CNA 1 transferred by herself Resident 27 using a Hoyer lift. As a result, Resident 27 fell and sustained a head injury and a scalp laceration requiring a transfer to GACH 1, where Resident 27 received six staples to the scalp laceration. 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 27.