Health inspection·October 27, 2023

F689 §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. §72523(a) 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 9/13/2023, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) sustained a fracture to his nose bone as well as a laceration measuring 1.0 centimeter ([cm] a unit of measurement) by 1.0 cm, with scant bleeding to the nasal bridge of his nose, following a mechanical lift (devices used to assist with transfer and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) accident on 9/12/2023. On 9/14/2023, CDPH conducted an unannounced visit to the facility to investigate the FRI report of Resident 1’s injury. Upon investigation it was determined that Resident 1 required two people to assist with his transfers and there was no order to use a mechanical lift to transfer Resident 1. Certified Nursing Assistant 1 (CNA 1) used a mechanical lift to transfer Resident 1 without assistance when the bar of the mechanical lift hit Resident 1 on his nose, resulting in a fracture and laceration. The facility failed to: 1. Ensure CNA 1 did not transfer Resident 1, using a mechanical lift without another staff’s assistance to transfer Resident 1 from his bed to a wheelchair. 2. Ensure CNA 1 followed the facility’s policy and procedure (P/P) titled, “Total Mechanical Lift,” to have two people present when transferring residents with a mechanical lift. As a result, on 9/12/2023, Resident 1 was struck in the nose by the bar of the mechanical lift and sustained a nasal (nose) bridge laceration (cut) with a nasal fracture (a break). Resident 1 was transferred to a General Acute Care Hospital (GACH) on 9/13/2023 where he was treated with IV ([intravenous] in the vein) antibiotics (medication used to treat bacterial infections) for his nasal laceration and nasal fracture. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, a 79-year-old male, was admitted to the facility on 11/4/2022 with a diagnosis of Alzheimer’s disease (a disease which slowly destroys memory and thinking skills) and muscle weakness. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 8/10/2023, indicated Resident 1’s cognitive (thinking) skills for daily decision making were severely impaired and Resident 1 required extensive assistance from two staff members when transferring from bed to chair. A review of the facility’s Fall Management Program note dated 9/8/2023, indicated the rehabilitation department recommended that Resident 1 use a two wheeled walker along with limited physical assistance from the nursing staff for mobility and completion of physical activities. A review of Resident 1’s Change of Condition (COC) Progress Note, dated 9/12/2023, indicated while Resident 1 was being assisted by CNA 1 to a wheelchair via a mechanical lift, Resident 1’s nose came into contact with the mechanical lift bar. The COC indicated Resident 1 sustained a cut to his nasal bridge which measured 1.0 cm by 0.1 cm. A review of Resident 1’s undated Care Plan, indicated Resident 1 had activities of daily living [(ADL) tasks such as eating, bathing, dressing, grooming and toileting] self-care performance deficits and required extensive assistance from two staff members during transfers between surfaces. A review of the facility’s Mechanical Lift List (a list to indicate which residents require a mechanical lift for transfers), dated 9/2023, indicated Resident 1’s name was not on the list. A review of Resident 1’s Physician order, dated 9/12/2023, indicated to obtain an X-ray of Resident 1’s nose. A review of Resident 1’s Radiology Report, dated 9/12/2023, indicated Resident 1’s nasal bone was fractured. A review of Resident 1’s Physician’s Order dated 9/12/2023, indicated to transfer Resident 1 to a GACH due to his nasal bone fracture. A review of the GACH’s Admission Record, indicated Resident 1 was admitted to the GACH on 9/13/2023. A review of the GACH’s Critical Care Medicine Consultation Report dated 9/13/2023, indicated Resident 1 to receive IV antibiotics for an infection of his nasal laceration. A review of the GACH’s Physician’s Order dated 9/13/2023, indicated Resident 1 to receive Ceftriaxone (a medication to treat bacterial infections) 1000 milligrams ([mg] a unit of measurement) IV daily for a “bloodstream infection.” A review of the GACH’s History and Physical (H&P), dated 9/14/2023, indicated Resident 1 had a nasal contusion (a bruise) on the bridge of his nose with a nasal bone fracture. During a telephone interview on 9/14/2023 at 11:44 a.m., CNA 1 stated when she transferred Resident 1 on 9/12/2023 to his wheelchair from his bed, using a mechanical lift, Resident 1 grabbed the mechanical lift’s bar and the bar hit Resident 1 on his nose. CNA 1 stated she did not have assistance from staff when she used the mechanical lift to transfer Resident 1 to his wheelchair. CNA 1 stated she decided to use the mechanical lift to transfer Resident 1 to his wheelchair because Resident 1 was not cooperating with her. CNA 1 stated there is a binder with a list of residents who required the use of a mechanical lift for transfer between surfaces, but she could not recall if Resident 1’s name was on the list. CNA 1 stated no other staff members were available to help her with the mechanical lift and stated there should be two staff members when using the mechanical lift to transfer the resident. During an interview on 9/14/2023 at 12:13 p.m., the Licensed Vocational (LVN 1) stated he went into Resident 1’s room (9/12/2023) because he heard a squeaky noise coming from the room that caught his attention, that was when he found CNA 1 holding the mechanical lift bar away from Resident 1’s face. LVN 1 stated CNA 1 told him the mechanical lift bar hit Resident 1’s nose. LVN 1 stated there was some scant bleeding from the top of Resident 1’s nose. LVN 1 stated there was no other staff member in Resident 1’s room assisting CNA 1 with the mechanical lift. LVN 1 stated there should be two staff members when using the mechanical lift for safety reasons. LVN 1 stated there is a binder at the nurse’s station with the appropriate transfer methods for each resident. LVN 1 stated Resident 1 was able to stand and transfer to his wheelchair with assistance from two staff members. During an interview on 9/15/2023 at 12:15 p.m., the Director of Staff Development (DSD) stated staff, including CNAs and licensed staff, have been in-serviced to have two staff members when using the mechanical lift. The DSD stated for safety reasons one staff member operates the lift while the other staff member ensures the resident is safe and not moving around. The DSD stated there is a binder at every nurse’s station with a list of residents who require the mechanical lift for transfer. The DSD stated Resident 1’s name was not on the list. During an interview on 9/15/2023 at 1:14 p.m., the Director of Rehabilitation (DOR) stated the Resident 1 required partial to moderate assistance with transfers and Resident 1 needed extra time for transfers due to the resident’s cognitive status. However, Resident 1 did not require the use of a mechanical lift for transfers. During an interview on 9/15/2023 at 1:58 p.m., the Director of Nursing (DON) stated when the mechanical lift is used, there should be two staff members transferring the resident for the resident’s safety. The DON stated Resident 1’s care plan intervention indicated the resident required the use of two staff members during transfers and Resident 1’s name was not on the Mechanical Lift List for residents who require the use of a mechanical lift for transfer. The DON stated CNA 1 was alone when she (CNA 1) used the mechanical lift to transfer Resident 1. The DON stated when interventions for the resident’s, who require two persons physical assistance, are not implemented and residents do not receive the appropriate assistance, there is a risk for residents to be injured. A review of the facility’s P/P titled “Total Mechanical Lift” revised 4/27/2023, indicated at least two people are present while resident is being transferred with the mechanical lift. The P/P indicated mechanical lifts are devices used to transfer individuals who require support for mobility which cannot be provided by the nursing staff alone. The facility failed to: 1. Ensure CNA 1 did not transfer Resident 1, using a mechanical lift without another staff’s assistance to transfer Resident 1 from his bed to a wheelchair. 2. Ensure CNA 1 followed the facility’s policy and procedure (P/P) titled, “Total Mechanical Lift,” to have two people present when transferring residents with a mechanical lift. As a result, on 9/12/2023, Resident 1 was struck in the nose by the bar of the mechanical lift and sustained a nasal (nose) bridge laceration (cut) with a nasal fracture (a break). Resident 1 was transferred to a General Acute Care Hospital (GACH) on 9/13/2023 where he was treated with IV ([intravenous] in the vein) antibiotics (medication used to treat bacterial infections) for his nasal laceration and nasal fracture. These violations jointly, separately, or in any combination, presented had a direct relationship to the health, safety, or security of patients.