Health inspection·September 19, 2024

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. §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 7/22/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding Resident 1 who sustained a left foot fracture after Housekeeper (HK 1) ran over her foot with an overfilled laundry cart (a large, blue, storage device with wheels used to deliver residents' clothing and clean linens in bulk). On 8/5/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI allegations. Upon investigation, CDPH determined on 7/20/2024 facility failed to prevent accident hazards and implement facility policy which resulted in HK 1 running over Resident 1's foot with an overfilled laundry cart, causing Resident 1's left foot fracture and rendering Resident 1 wheelchair dependent. The facility failed to: 1. Keep facility as free as possible from accident hazards including preventing laundry cart (a large, blue, storage device with wheels used to deliver residents' clothing and clean linens in bulk) overfill with clean linen and clothing preventing facility housekeeping from having a clear view when transporting the laundry cart around the facility. On 7/20/2024 HK 1 ran over Resident 1's left foot with an overfilled laundry cart while transporting it to Station 2. 2. Implement the facility policy and procedure titled, "Laundry Initiative Module 2: the Six-Step Laundry Process" which indicated when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering. As a result, Resident 1 sustained a fracture of the left medial (middle) cuneiform (bone in the mid foot) on 7/20/2024 at 7:00 a.m. Resident 1 was sent to a General Acute Care Hospital (GACH) for an evaluation of the left foot fracture. Resident 1, once independent in ambulation, became a wheelchair dependent for mobility after sustaining a facility induced left foot injury. A review of Resident 1's Admission Record indicated Resident 1, a 69 year old female, was admitted to the facility on 7/12/2021 with diagnoses including type 2 diabetes (a problem in the way the body regulates and uses sugar as a fuel), unspecified nondisplaced (the bone typically stays aligned in an acceptable position for healing) fracture of neck of right humerus (upper arm bone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), and generalized anxiety disorder (extremely worried or nervous-even when there is little or no reason to worry about them). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 6/12/2024 indicated Resident 1's had intact cognitive skills for daily decision making. The MDS indicated Resident 1 did not use any assistive devices for ambulation. The MDS indicated Resident 1 was able to walk 150 feet (ft) with supervision or touching assistance (staff provides verbal cues and/or touching/steadying but the resident completes the activity). A review of Resident 1's Health Status Note dated 7/20/2024 indicated the activity staff informed Licensed Vocational Nurse (LVN 1) Resident 1 was complaining of the left foot pain. The Registered Nurse (RN 1) and LVN 1 assessed Resident 1 and noted Resident 1 had swelling on the left foot and was not able to bear any weight on the left foot (support full body weight ). Resident 1 informed nursing staff she was hit from behind by the "big blue linen bucket" by HK 1, while walking towards the "double doors" near the activity room. Resident 1 informed RN 1 and LVN 1 she did not tell anyone about the incident, because HK 1 apologized and believed it was an accident. On 7/20/2024 Resident 1's physician (MD 1) ordered a STAT (immediate) X-ray (picture of the inside structures of the body), ice pack for left foot, and Motrin (medication for pain). A review of Resident 1's Change of Condition ([COC] - documentation of a resident's sudden change from regular state of being) evaluation dated 7/20/2024 indicated MD 1 was notified of Resident 1's accident on 7/20/2024 at 12:45 p.m. A review of Resident 1's care plan initiated on 7/20/2024, focusing on "Resident has left foot pain with swelling due to Resident 1 stated, she was bumped into from behind by the big blue laundry bucket," indicated the goal for Resident 1 was to improve pain. The care plan interventions included for Resident 1 to wear a controlled ankle movement ([CAM] foot brace that limits ankle and foot movement) boot on the left foot at all times, except when sitting or lying, non-weight bearing on the left foot and remind Resident 1 not to have weight bearing on the left foot. A review of Resident 1's X-ray) Report result indicated an X-ray of Resident 1's left foot was done on 7/20/2024 at 2:24 p.m., and the result was reported to the facility on 7/21/2024 at 1:05 p.m. The X-ray report result was as follows: no definite fracture identified; radiologist suggested to obtain additional X-ray views of the foot for further evaluation. A review of Resident 1's Health Status Note on 7/21/2024 indicated MD 1 was informed of Resident 1's left foot X-ray result and ordered for Resident 1 to be transferred to the GACH for evaluation of left foot fracture. A review of Resident 1's GACH Emergency Room (ER) After Visit Summary, dated 7/21/2024 indicated Resident 1 was seen in the ER for foot pain and was diagnosed with a fracture of the left cuneiform bone and was to follow up with an orthopedic (bone doctor) physician in three days. Resident 1 was discharged back to the facility on the same day she was seen in the ER, on 7/21/2024. The ER's After Visit Summary indicated cuneiform fractures could be caused by dropping a heavy object on the foot and could be treated by wearing a boot or brace for several weeks. A review of Resident 1's care plan initiated on 7/21/2024, focusing on "Resident has actual pain and discomfort related to incident on 7/20/2024, facility staff accidently ran over her foot with a laundry cart", indicated the goals for Resident 1 included achieving an acceptable level of pain control. A review of Resident 1's After Visit Summary 1, from her orthopedic physician visit dated 7/29/2024 indicated Resident 1 to always wear the CAM boot, except when sitting or lying, no-weight bearing on the left foot for four to six weeks, and come back to see the orthopedic physician in six weeks for a repeat X-ray. A review of Resident 1's Physician's Orders Summary Report indicated an order dated 7/29/2024 for no weight bearing on the left foot. On 8/5/2024 at 12:35 p.m., a blue laundry cart was observed parked in the hallway in front of the laundry room. The laundry cart was piled high with clean linens in plastic bags and covered with a white blanket. The approximate height of the laundry cart, including the clean linens, was over 5 ft tall. When standing behind it, the laundry cart obstructs the view of the hallway ahead. During a concurrent observation and interview on 8/5/2024 at 12:40 p.m., Resident 1 was sitting at the bedside eating lunch with her foot in a black orthopedic boot. Resident 1 stated that on the day she got injured she was walking toward the double doors on her unit when HK 1 came walking down the hall with the large blue laundry cart piled high with clothing and hit her from behind and ran over her left foot with the laundry cart. Resident 1 stated after HK 1 ran over her foot with the laundry cart, Resident 1 walked to her room to lay down in bed because "the pain was excruciating, and she wanted to forget about it." Resident 1 stated she went back to her room, so she "did not cry" in front of everyone because of the pain and did not tell anyone about it because it was an "accident," Resident 1 stated that a little while later HK 1 came to her room and apologized for running over her foot. Resident 1 stated she was able to walk before the accident but now she needed to use a wheelchair to move around in the facility. During an interview on 8/5/2024 at 1:04 p.m., LVN 1 stated Resident 1 was able to walk with a steady gait prior to getting her foot ran over by the laundry cart but now they have to provide her with a wheelchair because she had orders not to bear any weight on the left foot. During an interview on 8/5/2024 at 1:08 p.m., Activities Staff (ACT 1) stated Resident 1 attended activities on 7/20/2024 for a "coffee social" and around 11 a.m., Resident 1 asked for help back to her room which was unusual for her. ACT 1 asked Resident 1 why she needed help back to her room because she was usually ambulatory without assistance. ACT 1 stated Resident 1 informed her she could not walk because she had a "bump" on her left foot. ACT 1 stated she called LVN 1 over for help and LVN 1 assessed Resident 1's foot with RN 1 and placed Resident 1 in a wheelchair and took her to her room. During an interview on 8/5/2024 at 2:47 p.m., LVN 1 stated that before lunch time (between 11 a.m. and 12 p.m.) on 7/20/2024, ACT 1 informed her that something was wrong with Resident 1's left foot. LVN 1 stated she removed Resident 1's shoes and noted the resident's left foot was visibly swollen on the dorsal (top) part. LVN 1 stated Resident 1 stated that her left foot was ran over by a laundry cart that had stacks of clothes in it. LVN 1 stated Resident 1's MD 1 was informed of what had happened to Resident 1 and that her left foot was swollen and tender to the touch. LVN 1 stated Resident 1 verbalized her left foot "hurt a lot". During an interview on 8/5/2024 at 3:36 p.m., HK1 did not speak a commonly used language (English) and a housekeeping supervisor (HKS) was translating the interview with HK1. The HK1 stated she was pushing the blue laundry cart into Station 2 through the double doors, and she did not see Resident 1 but heard "ouch!" HK1 stated she stopped the cart, walked around the cart, and saw Resident 1 there. HK 1 stated Resident 1 told her she (HK1) hit her with the laundry cart. HK1 stated she asked Resident 1 if she was okay and she said "yes," she was okay. HK 1 stated she did not see Resident 1 walking in the hallway because the laundry cart was full of clean clothing, and it blocked her view. HK 1 stated the incident occurred around 7 a.m. on 7/20/2024. During a concurrent observation and interview on 8/6/2024 at 8:14 a.m., the blue laundry cart was parked in the hallway by the laundry room, the laundry cart was piled high with residents clothing in plastic bags on hangers and the plastic bags of clothes were covered by a white blanket. HK 1 was standing next to the blue laundry cart and the laundry cart and HK 1 was approximately the same height (HK 1 stated she was 5 ft tall). HK 1 with the scheduler (SCH) as a translator stated the blue laundry cart was the same laundry cart that she was pushing when she hit Resident 1. HK 1 stated the day of the accident, the laundry cart was piled high with clothing as it was during the observation. HK 1 acknowledged the laundry cart was piled too high and was blocking her visual field. During a concurrent interview and record review on 8/6/2024 at 11:15 a.m., the Director of Rehabilitation ([DOR] - specializes in techniques to restore muscle function and movement) reviewed Resident 1's Rehabilitation Evaluations from Physical Therapy (PT) and stated Resident 1 was previously discharged from PT Rehabilitation in February 2024 and was not using any assistive devices during that time and was able to walk 150 ft with hardly any assistance. The DOR stated Resident 1 had a high level of function at the time of discharge (2/2024) from Rehabilitation (rehab). The DOR stated Resident 1 was reevaluated for rehab services again on 7/23/2024 by PT and Occupational Therapy (OT) after her accident and now required a wheelchair and non-weight bearing on the left foot due to her injury. The DOR stated Resident 1 had a functional (ability to move and use a joint to perform activities of daily living) decline due to the left foot injury. During an interview on 8/6/2024 at 11:40 a.m., Resident 1 stated she was 5 ft 2 inches tall. Resident 1 stated she was feeling "antsy" from being stuck in her wheelchair because she likes to walk around. Resident 1 stated she was having a hard time propelling the wheelchair with her arms because she had an old right shoulder injury. Resident 1 stated she was stuck in her room since the accident unless staff pushed her around in the wheelchair. During an interview on 8/6/2024 at 12:06 p.m., the Director of Staff Development (DSD) stated to ensure resident safety, staff were to look around the carts when they were pushing them and not have the carts stacked too high, blocking their visual field. The DSD stated if the laundry cart was piled too high there was not a clear view, and someone could get hit with the cart. The DSD stated the accident between HK 1 and Resident 1 could have been prevented if HK 1 had a clear view and was able to see Resident 1. During an interview on 8/6/2024 at 12:37 p.m., the HKS stated HK 1 should have informed the charge nurse on duty or any nursing staff immediately about the accident, even if she thought Resident 1 was okay. The HKS stated the laundry carts should not be filled above the top of the cart. During an interview on 8/6/2024 at 2:15 p.m., the Director of Nursing (DON) stated Resident 1 was ambulatory prior to this incident and was now wearing a CAM boot and would be non-weight bearing for 4-6 weeks. During a review of the facility's P/P titled "Laundry Initiative Module 2: the Six-Step Laundry Process" revised 8/2024, the P/P indicated, when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering. Concluding, upon investigation, CDPH determined on 7/20/2024 facility failed to prevent accident hazards and implement facility policy which resulted in HK 1 running over the Resident 1's foot with an overfilled laundry cart causing Resident 1 to sustain a left foot fracture rendering Resident 1 wheelchair dependent. The facility failed to: 1. Keep facility as free as possible from accident hazards including preventing laundry cart (a large, blue, storage device with wheels used to deliver residents' clothing and clean linens in bulk) overfill with clean linen and clothing preventing facility housekeeping from having a clear view when transporting the laundry cart around the facility. On 7/20/2024 HK 1 ran over Resident 1's left foot with an overfilled laundry cart while transporting it to Station 2. 2. Implement the facility policy and procedure titled, "Laundry Initiative Module 2: the Six-Step Laundry Process" which indicated when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering. As a result, Resident 1 sustained a fracture of the left medial cuneiform on 7/20/2024 at 7:00 a.m. Resident 1 was sent to a GACH for an evaluation of the left foot fracture. Resident 1, once independent in ambulation, became a wheelchair dependent for mobility after sustaining a facility induced left foot injury. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probably that death or serious physical harm would result.