Health inspection·July 12, 2024

§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(a)(2) Nursing Service -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. 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 5/9/2024, the California Department of Public Health (CDPH) received a complaint regarding an allegation related to quality of care and patient safety related to falls. On 5/15/2024, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. The facility failed to provide care and services to prevent falls by failing to ensure Resident 2 was transferred using a Hoyer lift (an assistive medical device used to transfer residents 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) from the bed to a wheelchair, with assistance from another staff as indicated in Resident 2’s Minimum Data Set (MDS – a standardized assessment and care-screening tool). As a result, Resident 2 fell from the Hoyer lift to the floor, complained of severe pain to the head, neck and back, and was transferred to a General Acute Care Hospital (GACH) for further evaluation and treatment for five days. The facility admitted Resident 2, a 42-year-old male resident, on 10/9/2023 and was last readmitted on 4/21/2024. Resident 2’s diagnoses included injury at unspecified level of cervical spinal cord (the neck region of the spinal column or backbone), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and generalized muscle weakness. A review of Resident 2’s MDS, dated 1/15/2024, indicated the resident was able to understand and be understood. The MDS indicated Resident 2 was dependent assist (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for bed-to-chair transfer. A review of Resident 2’s Care Plan, developed on 10/9/2023, for resident’s risk for Activities of Daily Living (ADL) and mobility decline and requiring assistance related to history of motor vehicle accident (MVA) with fracture (a broken bone) and quadriplegia, indicated Resident 2 needed assistance of two persons for morning (a.m.) and afternoon (p.m.) care and dependent assist for Hoyer lift transfer. A review of Resident 2’s Fall Risk Observation/Assessment, dated 4/8/2024, indicated the resident’s fall risk score was 22 (a score above 16 to 42 represented high fall risk). A review of Resident 2’s Change of Condition notes (COC – a major decline in a resident’s status), dated 4/16/2024 at 4:45 p.m., indicated the resident had a fall on 4/16/2024. The COC indicated Resident 2 was observed sitting in an upright position on the floor, in front of his wheelchair. The COC indicated Resident 2 stated he fell from the Hoyer lift and in the process of the fall, the metal sling bar spun around and hit his head. The COC indicated Resident 2 complained of severe head and back pain, rated at 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain ever felt). A review of Resident 2’s Medication Administration Record (MAR) for April 2024 indicated on 4/16/2024 at 5:01 p.m., the resident was given oxycodone 10 milligrams (mg- a unit of measurement) one tablet for pain of 10 out of 10. A review of the Order Summary Report, dated 3/14/2024, indicated an order for oxycodone (medication used to relieve moderate to severe pain), give one tablet by mouth every four hours as needed for severe breakthrough pain (pain that may occur while you are taking medicine to manage chronic pain) 7-10/10. A review of Resident 2’s Interdisciplinary Team (IDT-a coordinated group of experts from several different fields working for the resident’s benefit) Notes, dated 4/17/2024 at 9:12 a.m., for Fall/How it happened: 4/16/2024 at 4:45 p.m., indicated per CNA 1, Resident 2 was transferred into the wheelchair via Hoyer lift. As CNA 1 finished unhooking the Hoyer sling from the lift, Resident 2’s bottom began to slide towards the front of the wheelchair sliding off the chair and onto the floor. The IDT Notes indicated CNA 1 stated Resident 2 did not hit his head but was complaining of increased neck and back pains. The IDT Notes indicated Resident 2 requested to go to the Emergency Room (ER) due to pain. A review of Resident 2’s GACH Emergency Department notes, dated 4/16/2024 at 6:24 p.m., indicated the resident’s chief complaint was that he fell from a Hoyer lift approximately three feet, hit his head on the arm bar, and complained of head pain. The current level of pain was moderate. A review of Resident 2’s GACH Discharge Summary, dated 4/21/2024, indicated the resident was admitted on 4/16/2024 and was discharged on 4/21/2024. The discharge summary indicated Resident 2 complained of extensive headache and was given Fioricet (medication to treat headaches). The discharge summary indicated discharge diagnoses of headache and body aches. During an interview, on 5/16/2024 at 10 a.m., Resident 2 stated about a month ago he (Resident 2) fell from the Hoyer lift. Resident 2 stated CNA 1 got him out of the bed. Resident 2 stated CNA 1 placed the sling under him and began to crank (raise the resident from place of rest) the Hoyer lift. Resident 2 stated as he was lowered onto the wheelchair, he began to slide down to the floor. Resident 2 stated his butt hit the base of the Hoyer lift and the floor. Resident 2 stated CNA 1 left him (Resident 2) on the floor, to get CNA 2 then CNA 1 and CNA 2 pulled Resident 2 by his arms. Resident 2 stated he told CNA 1 and CNA 2 to stop because they were hurting him. Resident 2 stated CNA 1 and CNA 2 used the sling but did not cross the bottom straps and he swung as they (CNA 1 and CNA 2) were lifting him up and hit his head on the metal sling bar. Resident 2 stated he slipped off the Hoyer lift and hit his right buttock on the floor. Resident 2 stated he was in pain, was crying, and was yelling for help and Licensed Vocational Nurse 1 (LVN 1) came in and assisted Resident 2 back into his bed. During an interview, on 5/16/2024 at 2:32 p.m., LVN 1 stated that one day (LVN could not recall the specific day or time), CNA 2 walked out of Resident 2’s room and notified LVN 1 that Resident 2 fell. LVN 1 stated she observed Resident 2 sitting on the floor facing the Hoyer lift, with a wheelchair behind Resident 2. LVN 1 stated she and CNA 1 tried to get Resident 2 up but Resident 2 was heavy. LVN 1 stated CNA 2 came back to assist her and CNA 1 placed Resident 2 in the wheelchair. During an interview, on 5/16/2024 at 2:57 p.m., the Assistant Director of Nursing (ADON) stated she spoke to Resident 2 privately after the fall and Resident 2 stated CNA 1 was placing him from bed to wheelchair using the Hoyer lift. The ADON stated CNA 1 was moving Resident 2 alone without assistance. The ADON stated Resident 2 stated when CNA 1 had removed the sling off the Hoyer lift and stepped away he (Resident 2) slid off the wheelchair. During an interview, on 5/20/2024 at 10:23 a.m., the Director of Nursing (DON) stated patient safety is put at risk if equipment is not used properly. The DON stated CNA 1 did not position Resident 2 in the wheelchair correctly and Resident 2 slipped off. The DON stated it would have been beneficial if Resident 2 had a two-person assist because Resident 2 was a risk for falls. A review of the facility’s policies and procedures titled, “Safe Lifting and Movement of Residents,” revised on 7/2017, indicated, “In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents…. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.” A review of CNA 1’s Orientation and Skills Checklist dated 12/14/2023, indicated CNA 1 was evaluated for understanding use of Hoyer lift (two person). The facility failed to provide care and services to prevent falls by failing to ensure Resident 2 was transferred using a Hoyer lift from the bed to a wheelchair, with assistance from another staff as indicated in Resident 2’s MDS. As a result, Resident 2 fell from the Hoyer lift to the floor, complained of severe pain to the head, neck and back, was transferred to a GACH for further evaluation and treatment for five days. 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.