Health inspection·December 23, 2024

42 CFR §483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. 42 CFR 483.25 (d)(1)(2) Accidents. The facility must ensure that: The resident environment remains as free from accident hazards as is possible. Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CFR § 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 11/4/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 1 fell and sustained a fracture (broken bone) during transfer with a Hoyer lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places), from his bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). On 11/5/2024, the CDPH made an unannounced visit to the facility to investigate the FRI. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift to transfer Resident 1 from the bed to a Geri-chair. As a result, Resident 1 fell and sustained an acute (immediate) fracture (broken bone) of the fifth cervical (relating to the neck) (C5) vertebra (bone in the spine). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment. Resident 1 was discharged back to the facility on 11/3/2024, complained of excruciating pain all over his body due to the fall, and was transferred back to the GACH on 11/4/2024 where he was admitted and treated. Resident 1 was discharged back to the facility on 11/10/2024 (6 days later). Resident 1 was a 39-year-old male, originally admitted to the facility on 5/18/2024 and readmitted on 10/2/2024 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), hypertension ([HTN]- high blood pressure), anxiety (feeling of fear, or worry), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical (H&P), dated 10/4/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/9/2024, indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) on staff with a two-person physical assist for transfer (how the resident moves between surfaces) and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's care plan titled "ADL Self Care Performance Deficit", dated 10/14/2024, indicated Resident 1 had a self-care deficit related to limited mobility, and quadriplegia. The care plan interventions indicated facility staff will provide total assistance for transfers with the use of a Hoyer lift. A review of Resident 1's situation, background, assessment, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents) report, dated 11/3/2024 at 11:00 a.m., indicated Resident 1 fell on his back and hit his head during transfer from the bed to a Geri-chair. The SBAR indicated Resident 1 was assisted back to the bed and complained of back and neck pain rated at 7 out of 10, on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). A review of Resident 1's GACH Emergency Room (ER) admission record, dated 11/3/2024 at 12:19 p.m., indicated Resident 1 was seated on a Hoyer lift when it tipped over causing the resident to fall to the ground and hit his head. The GACH ER admission record indicated Resident 1 complained of left head pain rated at 7 out of 10 on the pain scale, post (after) fall. A review of Resident 1's progress note dated 11/3/2024 at 1:24 p.m., indicated Resident 1 was transferred to the GACH emergency room (ER) for evaluation due to a fall and pain. A review of Resident 1's GACH ER Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 11/3/2024 at 1:08 p.m., indicated acute fracture through the C5 vertebral body (recent break in the bone of the central part of the fifth cervical vertebra, which is located in the neck). A review of Resident 1's GACH ER note, dated 11/3/2024 at 1:28 p.m., indicated Resident 1 was administered morphine (medication used to treat moderate to severe pain) four (4) milligrams (mg, unit of measurement) intramuscularly (IM, injection into the muscle) for pain. A review of Resident 1's GACH ER note, dated 11/3/2024 at 2:44 p.m., indicated Resident 1 required a cervical collar (a medical device that supports neck and spine) and a follow-up with neurosurgery (surgery to the brain or spinal cord) within 6 to 8 weeks. A review of Resident 1's progress note (from the facility), dated 11/3/2024 at 6:15 p.m., indicated Resident 1 returned to the facility on 11/3/2024 at 6:15 p.m. A review of Resident 1's progress note, dated 11/3/2024 at 11:30 p.m., indicated Resident 1 reported an excessive tingling sensation and discomfort to all extremities (arms and legs). The progress note indicated Resident 1 reported having 10 out of 10 pain all over his body. A review of Resident 1's progress note, dated 11/4/2024 at 1:00 a.m., indicated Resident 1 was transferred back to the GACH for evaluation and treatment. A review of Resident 1's GACH record, dated 11/4/2024 at 1:39 a.m., indicated Resident 1 presented to the ER for pain to the bilateral upper and lower extremities. A review of Resident 1's GACH medication record, dated 11/6/2024 at 2:46 p.m., indicated Resident 1 was administered baclofen (medication to treat muscle spasms and pain) 10 mg for pain. A review of Resident 1's GACH medication record, dated 11/8/2024 at 9:37 a.m., indicated Resident 1 was administered fentanyl (medication used to treat severe pain) 50 microgram (mcg, unit of measurement) intravenously (IV, into the vein) for pain. A review of Resident 1's GACH medication record, dated 11/9/2024 at 10:30 p.m., indicated Resident 1 was administered morphine 4 mg IV for pain. A review of Resident 1's GACH record, dated 11/10/2024, indicated Resident 1 was discharged back to the facility. During a telephone interview on 11/5/2024 at 10:14 a.m., CNA 1 stated Resident 1 could not get up alone and required a two-person assist for ADLs. CNA 1 stated Resident 1 required a Hoyer lift for transfer from the bed to Geri-chair. CNA 1 stated on 11/3/2024 at 10:00 a.m., she was assisting Resident 1 with a Hoyer lift transfer from the bed to a Geri-chair. CNA 1 stated Resident 1 was seated on the Hoyer lift sling (device that holds a patient during a transfer). CNA 1 stated there were four straps, two in the front of Resident 1 and two on the back of Resident 1. CNA 1 stated she attached the four sling straps to the Hoyer lift and stood behind the Hoyer lift while lifting Resident 1 from the bed. CNA 1 stated Resident 1 was approximately four (4) feet from the ground. CNA 1 stated Resident 1 fell to the ground and the Hoyer lift tipped over onto Resident 1. CNA 1 stated it could have been a safer transfer had another staff assisted in transferring Resident 1, as she (CNA 1) was alone. CNA 1 stated she was busy rushing to complete the care of her other assigned residents and did not ask for assistance. CNA 1 stated Resident 1's fall could had been avoided if she asked for assistance while transferring Resident 1 with the Hoyer lift. During a telephone interview on 11/5/2024 at 11:07 a.m., Resident 1 stated he was admitted to the GACH on 11/4/2024 due to a neck bone fracture and pain. Resident 1 stated on 11/3/2024 around 10:00 a.m., CNA 1 transferred him (Resident 1) from the bed to a Geri-chair using a Hoyer Lift. Resident 1 stated the Hoyer lift tipped over, he fell to the ground and the Hoyer lift fell on top of him. Resident 1 stated he sustained a neck fracture. Resident 1 stated he was in pain. During an interview on 11/5/2024 at 11:22 a.m., CNA 2 stated on the morning of 11/3/2024 around 10:30 a.m., she (CNA 2) heard "help, help" coming from Resident 1's room. CNA 2 stated she went to Resident 1's room and observed the resident on the floor with the Hoyer lift on the resident. CNA 2 stated she and four other staff assisted Resident 1 into bed. CNA 2 stated while Resident 1 was assisted into his bed, Resident 1 complained of neck pain. CNA 2 stated to prevent accidents and keep residents safe; staff should not operate the Hoyer lift using a one person assist. During a concurrent interview and record review on 11/5/2024 at 1:20 p.m., with Occupational Therapist (OT, a healthcare provider who helps you improve your ability to perform daily tasks) 1, Resident 1's "Occupational Therapy Note", dated 10/8/2024 was reviewed. OT 1 stated Resident 1's upper extremities ([UE] arms) and lower extremities ([LE] legs) were impaired (loss of a physical ability). OT 1 stated Resident 1 required total assistance (two or more persons assist) with mobility and transfer. OT 1 stated due to Resident 1's UE and LE impairment it was safer for staff to use a Hoyer lift while transferring Resident 1. OT 1 stated the Hoyer lift should have been two persons assist to prevent falls, injury, and to keep Resident 1 safe. During an interview on 11/5/2024 at 2:25 p.m., the Director of Nursing (DON) stated Resident 1 was dependent with care and required two-person assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated there should have been a two-person physical assist when operating the Hoyer lift for the residents' safety, and to prevent falls, and injury. A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents", revised 7/2017, indicated the facility will make the environment as free of accident hazards as possible. The P&P indicated the facility's priority was resident safety, supervision, and assistance to prevent accidents. A review of the facility's P&P titled "Safe Lifting and Movement of Residents", undated, indicated the facility will protect the safety and well-being of residents and staff. The P&P indicated the facility will promote quality care, use appropriate techniques and devices to lift and transfer residents. A review of an undated Manufacturer's User Manual titled "Invacare ([Invacare] manufacture of long-term care medical products), indicated a recommendation to use two persons assist for lifting and transferring procedures. A review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 9/2020, indicated the CNAs responsibilities and accountabilities included implementing care according to the care plan. The CNA Job Description indicated the CNA's responsibility was to help residents with ADLs, and proper lifting and transitioning from bed to wheelchair, wheelchair to bed. The facility failed to: 1. Ensure CNA 1 provided a two-person physical assist when using a Hoyer Lift to transfer Resident 1 from the bed to a Geri-chair. As a result, Resident 1 fell and sustained an acute fracture of the fifth cervical (C5) vertebra. Resident 1 was transferred to a GACH for evaluation and treatment. Resident 1 was discharged back to the facility on 11/3/2024, complained of excruciating pain all over his body due to the fall, and was transferred back to the GACH on 11/4/2024 where he was admitted and treated. Resident 1 was discharged back to the facility on 11/10/2024 (6 days later). This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.