Health inspection·September 20, 2024

§483.25 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 residents' choices. 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. California Code of Regulations, Title 22, Section 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. § 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. 22 CFR § 72637. General Maintenance. (c) All buildings, fixtures, equipment, and spaces shall be maintained in operable condition. (d) Personnel shall be employed to provide preventive maintenance and to carry out the required maintenance program. (e) Equipment provided shall meet all applicable California Occupational Safety and Health Act requirements in effect at the time of purchase. All portable electrical medical equipment designed for 110-120 volts, 60 hertz current, shall be equipped with a three wire grounded power cord with a hospital grade three prong plug. The cord shall be an integral part of the plug. On 8/5/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) and complaint alleging Resident 1 fell to the ground during a transfer from a wheelchair to the bed via Hoyer lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places), when the Hoyer lift strap broke. On 8/12/2024, the CDPH conducted an unannounced visit at the facility to investigate the incident. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist when using a Hoyer Lift to transfer Resident 1 from a wheelchair to the bed in accordance with the facility's P&P titled "Fall Management System", revised 12/2023, 2. Ensure that CNA 1 properly assessed the Hoyer Lift for any damages prior to use. As a result, Resident 1 fell, sustained a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone). During an interview on 8/12/2024 at 10:50 a.m., with Resident 1, Resident 1 stated on 8/2/2024 around 3:00 p.m., CNA 1 transferred her from the wheelchair to the bed using a Hoyer lift. Resident 1 stated the Hoyer lift sling broke, and she fell. Resident 1 stated she had right femur surgery. Resident 1 stated she was unable to perform her bicycle exercises, was very upset, and was in pain. Resident 1 was a 73-year-old female, admitted to the facility on 7/12/2022 with diagnoses including diabetes (abnormal blood sugar), hypertension (high blood pressure), and muscle weakness (decrease in muscle strength). A review of Resident 1's History and Physical (H&P), dated 7/9/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, 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) with two persons physical assist for transfer (how the resident moves between surfaces including to or from bed, chair, wheelchair, or standing position). A review of Resident 1's "Fall" report dated 8/2/2024 timed at 3:45 p.m., indicated Resident 1 required a Hoyer lift for transfer. The report indicated on 8/2/2024, Resident 1 was being transferred from the wheelchair to the bed. The report indicated during the transfer, the Hoyer lift sling broke and Resident 1 fell on the floor. The report indicated Resident 1's right leg was noted with slight swelling. The report indicated Resident 1 was assisted back to bed and reported 10 out of 10 pain on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain) to her right leg. A review of Resident 1's Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/2/2024, timed at 3:55 p.m., indicated on 8/2/2024, at 3:50PM, Resident 1 slid off the Hoyer lift on to her right leg, when the lift's sling snapped (broke). The SBAR indicated Resident 1's right leg was noted with slight swelling and the resident reported a pain level of 10 out of 10. A review of Resident 1's Order Summary, dated 8/2/2024, indicated X-ray (a photographic image of a part of the body) of the right knee, and right hip. A review of Resident 1's X-ray result dated 8/2/2024, indicated acute (sudden) comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur. A review of Resident 1's Progress Note dated 8/3/2024 timed at 9:30 a.m., indicated Resident 1 was transferred to the GACH for further evaluation and treatment due to a fall. A review of Resident 1's GACH Admission Record, dated 8/3/2024, indicated Resident 1 was admitted to the GACH on 8/3/2024 with a diagnosis of acute right femoral fracture. A review of Resident 1's GACH 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 8/3/2024 timed 4:05 p.m., indicated comminuted fracture of the right distal femur. A review of Resident 1's GACH Physician Daily Progress Note dated 8/5/2024, indicated Resident 1 had an ORIF surgery for a right distal femur fracture. DA review of Resident 1's GACH Discharge Note, dated 8/8/2024, indicated Resident 1 was discharged back to the facility. A review of Resident 1's Progress Note dated 8/8/2024 timed 3:07 p.m., indicated Resident 1 returned to the facility from the GACH with a diagnoses of status post (after) right knee ORIF. During an interview on 8/12/2024 at 3:00 p.m., with CNA 3, CNA 3 stated, on 8/2/2024 around 3:30 p.m., the Director of Nursing (DON) notified her that Resident 1 fell from the Hoyer lift, was on the floor, and the DON needed assistance to transfer Resident 1 back to bed. CNA 3 stated she went to Resident 1's room and observed Resident 1 on the floor. CNA 3 stated the Hoyer lift strap was broken. CNA 3 stated the laundry aid ([LA] person who works in a facility washing and folding laundry) was responsible for checking the Hoyer lift straps for torn pieces and tears every wash. CNA 3 stated CNAs were responsible for checking the Hoyer lift prior to use. During an interview on 8/12/2024 at 3:38 p.m., with LA 1, LA 1 stated she was responsible for checking the Hoyer lift sling for any damages prior to washing and before folding. LA 1 stated after the sling was checked and good for use, she signed and initialed the facility's sling log. LA 1 stated reported to the maintenance supervisor ([MS] person responsible for repairs and keeping the facility safe and functional) for damaged and broken slings. LA 1 stated the MS was responsible for replacing damaged the slings. During a concurrent interview and record review on 8/12/2024 at 4:10 p.m., with MS 1, the facility's sling logs dated 7/2024, and 8/2024 were reviewed. MS 1 stated there was no documentation indicating the slings were checked from 7/31/2024 through 8/8/2024. MS 1 stated he and other laundry staff were supposed to check the slings daily to ensure they were in good condition. MS 1 stated he was also responsible for the Hoyer lift's maintenance and replacement when damaged. MS 1 stated the facility's staff failed to check the sling and placed residents at risk for falls and injuries. During an interview on 8/12/2024 at 4:25 p.m., with the DON, the DON stated on 8/2/2024 at 3:30 p.m., CNA 1 notified her that while CNA 1 was transferring Resident 1 from the wheelchair to the bed with the Hoyer lift, the Hoyer lift's sling strap broke. The DON stated she immediately went to Resident 1's room and observed Resident 1 on the floor next to her bed. The DON stated she (DON) and six other staff assisted Resident 1 into bed. The DON stated Resident 1 complained of right leg pain level 10 out of 10. The DON stated Resident 1 was dependent and required two persons 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 CNAs were responsible for checking the Hoyer lift slings for tears and torn pieces prior to use. During an interview on 8/12/2024 at 4:35 p.m., with the Director of Staff Development (DSD), the DSD stated there should have been a two-person physical assist when operating the Hoyer lift. The DSD stated staff should assess the Hoyer lift sling(s) prior to each use for the residents' safety and to prevent falls and injuries. During an interview on 8/13/2024 at 10:53 a.m., with CNA 1, CNA 1 stated on 8/2/2024 around 3:15 p.m., she was assisting Resident 1 with a Hoyer lift transfer from the wheelchair to bed. CNA 1 stated Resident 1 was seated in the wheelchair and the Hoyer lift sling was under Resident 1. CNA 1 stated there were four straps, two in 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. CNA 1 stated while standing behind Resident 1 as soon as she started to lift Resident 1 with the Hoyer lift from the wheelchair, she (CNA 1) heard a loud noise. CNA 1 stated Resident 1 immediately fell to the floor. CNA 1 stated she observed the right front sling strap was broken. CNA 1 stated she notified the DON right way. CNA 1 stated she was aware that Resident 1 was a two persons physical assist for transfer, and she should have asked another staff for assistance before transferring Resident 1 with the Hoyer lift. CNA 1 stated she was busy rushing to get her other assigned residents' care done, did not ask for assistance, and did not assess the Hoyer lift prior to use. CNA 1 stated Resident 1's fall could have been avoided if she asked for assistance and assessed the Hoyer lift prior to use. During a concurrent observation and interview on 8/13/2014 at 11:31 a.m., with the Administrator (ADM), in the ADM's office, the Hoyer lift sling used during Resident 1's transfer on 8/2/2024 was observed. The ADM stated the front right strap of the sling was broken, and the other three straps (front left side, and two on the back side) were torn, worn, and ragged (torn or worn to tatters). The ADM stated the sling was unsafe for use and should have been thrown out. A review of the facility's policy and procedure (P&P) tilted "Fall Management System", revised 12/2023, indicated the facility will provide an environment free of accident hazards. The P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls. A review of an undated Manufacturer's User Manual titled "Invacare ([Invacare] manufacture of long-term care medical products), Manual/Electric Portable Patient Lift," indicated staff will read the manual before using the Lift. The manual indicated a recommendation to use two persons assist for lifting and transferring procedures. The manual also indicated a one-person assist could be used based on the evaluation of the health care professional for each individual case. A review of an undated Manufacturer's Operations and Maintenance Manual titled, "Patient Slings," indicated staff will read the manual before using the slings. The manual indicated staff will inspect the sling(s) for wear, tears, loose stitching, or broken sling(s)and immediately discard any damaged slings to prevent injury. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist when using a Hoyer Lift to transfer Resident 1 from a wheelchair to the bed in accordance with the facility's P&P titled "Fall Management System", revised 12/2023. 2. Ensure that CNA 1 properly assessed the Hoyer Lift for any damages prior to use. As a result, Resident 1 fell, sustained a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone). 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.