Health inspection·September 18, 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; 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. § 72311(a)(2) - 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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and On 8/5/24, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding Resident 1 who fell from the bed during transfer by a Certified Nursing Assistant (CNA 1) from a shower chair back to bed and sustained two lacerations on the scalp (head), one on the right side of the head and another on the front of the head (unspecified location) and the right arm skin tear that resulted in transfer to a General Acute Care Hospital (GACH). On 8/7/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI allegations. Upon investigation, CDPH determined the facility failed to prevent Resident 1 from falling out of bed when CNA 1 transferred Resident 1 from a shower chair back to bed. The facility failed to: 1. Ensure CNA 1 asked another staff to assist with transferring Resident 1 from a shower chair back to bed via a mechanical lift (lift used by caregivers to safely transfer residents) in attempt to remove linen and mechanical lift sling from a bed underneath the resident while the resident was positioned too close to the edge of bed. 2. Ensure Resident 1's care plan titled, "Self-Care Performance Deficit" included how staff will transfer the resident between surfaces to prevent falls. As a result, Resident 1 fell from a bed when CNA 1 was removing a mechanical lift sling and linen from a bed underneath the resident on 7/26/24. Resident 1 sustained two lacerations on the scalp (head), one on the right side of the head and another on the front of the head (unspecified location) and the right arm skin tear. On 7/26/24 at 12:15 p.m., Resident 1 was transferred to a GACH, where the resident underwent suturing of lacerations and was admitted to the GACH's telemetry unit (unit for cardiac [heart] monitoring) for further evaluation and treatment. A review of Resident 1's Admission Record, indicated Resident 1, a 82 year old male, was admitted to the facility on 11/01/2023 and readmitted 12/19/2023 with diagnoses including hemiplegia (paralysis of one side of the body), hemiparesis (weakness of one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply), type 2 diabetes mellitus (a condition in which the body fails to process sugar correctly), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities) and limitation of activities due to disability. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 5/21/2024, indicated Resident 1 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort, assistance of two or more helpers is required for the resident to complete the activity) on staff for transfer between surfaces (chair/bed to chair transfer) and all activities of daily living (ADLs) including dressing, personal hygiene, oral hygiene, toileting, and showering. The MDS indicated Resident 1 was incontinent (inability to control bladder and bowel functions) of urine and bowel and had a history of falls with injuries. The MDS did not indicate the resident's need for mechanical lift for transfer between surfaces. A review of Resident 1's History and Physical (H&P) dated 12/20/23, the H&P indicated Resident 1 had no capacity to make decisions. A review of Resident 1's care plan titled, "Resident at risk for fall related to poor safety awareness, cognitive loss, and behavior of getting up unassisted, putting legs by the edge of the bed" dated 5/21/2024, indicated the resident was recognized as risk for falls. The care plan goal for Resident 1 was to minimize episode of falls through the next review date of 9/7/2024. The Care Plan interventions included to provide extensive staff assistance to Resident 1 with getting in and out of bed and to conduct frequent visual check. A review of Resident 1's care plan titled "Self-Care Performance Deficit" dated 5/21/24, related to impaired function and mobility, cognition, diagnosis of dementia, and depression (persistent feeling of sadness and loss of interest in activities) indicated staff will assist Resident 1 with ADLs as needed. The care plan did not include information about mechanical lift for resident's transfer between surfaces or what staff approach would be to transfer the resident between surfaces. A review of Resident 1's Nurses Progress Note dated 7/26/24, indicated Resident 1 fell on 7/26/24 at 9:20 a.m., while CNA 1 was transferring the resident from shower chair to bed by using a mechanical lift by herself. The Nurses Progress Notes indicated Resident 1 was totally dependent on staff and required two-persons physical assistance with care. The Nurses Progress Note indicated Resident 1 sustained a bump on the forehead, skin tear on the right arm, and laceration on the right side of the head. The Nurses Progress Note indicated 911 (a phone number used to contact emergency services) was called and the resident was transferred to the GACH on 7/26/2024 at 12:15 p.m. A review of Resident 1's GACH report titled "History of Present Illness (HPI)," indicated Resident 1, "was being helped after shower to transfer back to bed when he fell from the bed to the floor and hit his head." The HPI indicated Resident 1 sustained two lacerations to his scalp which were repaired with sutures (a stitch or row of stitches holding together the edges of a wound) by emergency department (ED) physician. A review of Resident 1's GACH report titled "Clinical Impression," indicated Resident 1 had "a head injury, fall after getting a shower, pneumonia (an infection of the lungs), and acute respiratory failure (caused by a disease or injury that affects the breathing) with hypoxia (low levels of oxygen)." The Clinical Impression report indicated Resident 1's, "lacerations were treated/repaired, oxygen three liter per minute ([L/min]-unit of oxygen flow measurement) via nasal cannula (a thin, small flexible tubes placed into nostrils that delivers oxygen) and antibiotic (medication to treat infection) was ordered for Resident 1." The Clinical Impression report indicated Resident 1 was admitted to the telemetry unit for further evaluation and treatment. During an interview on 8/7/24 at 12: 46 p.m., CNA 1 stated she had a high workload and responsibilities that included residents' hygiene care, residents' feeding, bathing, ambulation (walking) assistance, and monitoring the resident's vital signs. CNA 1 stated she was attempting to transfer Resident 1 by using a mechanical lift from a shower chair to the bed after the resident was showered. CNA 1 stated she was intended to change the bed linen. CNA 1 stated when she lowered the lift's sling down the resident was positioned closed to the edge of the bed so when she was removing the sling and bed linen underneath the resident, the resident's leg slipped, causing him to fall. CNA 1 stated Resident 1 landed on the floor, resulting in a head injury and a skin tear on the arm. CNA 1 stated given how busy the facility's staff were, and her having assigned nine residents to care for with three of nine residents needed a shower on 7/26/2024, she felt she could not request an assistance from other staff to transfer Resident 1 to bed. CNA 1 stated Resident 1 needed a two-persons assistance due to his weight and his total dependance on staff for assistance with all transfers. CNA 1 stated Resident 1's fall was avoidable if she had asked a second person to assist her with use of mechanical lift to transfer Resident 1 to bed. During an interview on 8/7/24 at 2:06 p.m., the Licensed Vocational Nurse (LVN 1) stated she was passing medications when the incident (Resident 1's fall) happened on 7/26/2024. LVN 1 stated a Restorative Nursing Assistant (RNA 1) summoned her to go to Resident 1's room. LVN 1 stated when she walked into Resident 1's room, the resident was on the floor and was bleeding from his head and from a skin tear on his right arm. LVN 1 stated CNA 1 was removing Resident 1 linen and the sling from a mechanical lift underneath the resident when she rolled Resident 1 over that was when the resident fell. LVN 1 stated CNA 1 should have had an assistance from another staff to place Resident 1 back to bed as Resident 1 was very tall. LVN 1 stated Resident 1 fall was avoidable if CNA 1 had another staff to assist her with Resident 1 transfer to bed. During an interview on 8/7/24 at 3:09 p.m., the Occupational Therapist ([OT 1] a professional who provides services to increase and/or maintain a person's ability to participate in everyday life activities) stated Resident 1 required a two-persons assistance during care. The OT 1 stated CNAs and licensed staff were instructed to use two-persons assistance during Resident 1 transfers between surfaces as Resident 1 was a high risk for fall. The OT 1 stated Resident 1's fall could have been avoided if the resident had not been positioned so close to the edge of the bed, especially given his size. OT 1 stated when the resident shifted his body weight, he was too near the edge of the bed, which led to the fall. OT 1 stated for transfers Resident 1 required a mechanical lift with the assistance from two persons. During an interview on 8/7/24 at 4 p.m., the Administrator (ADM) stated on 7/26/2024 Resident 1 was transferred out to the GACH due to injuries related to his fall. The ADM stated Resident 1's fall was avoidable because if CNA 1 had used two persons assistance to transfer the resident back to bed, the resident would not have fallen. A review of facility's policy and procedures (P&P) titled "Falls Management" dated 5/26/2021, indicated "Residents will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury." A review of facility's P&P titled "Safe Lifting and Movement of Residents" dated 7/2017 indicated "Nursing staff in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis, staff will document resident's transferring and lifting needs in the care plan, such assessment shall include resident's preferences for assistance, resident's mobility (degree of dependency), resident's size, weight bearing ability, and the resident cognitive status." The facility failed to: 1. Ensure CNA 1 asked another staff to assist with transferring Resident 1 from a shower chair back to bed via a mechanical lift (lift used by caregivers to safely transfer residents) in attempt to remove linen and mechanical lift sling from a bed underneath the resident while the resident was positioned too close to the edge of bed. 2. Ensure Resident 1's care plan titled, "Self-Care Performance Deficit" included how staff will transfer the resident between surfaces to prevent falls. As a result, Resident 1 fell from a bed when CNA 1 was removing a mechanical lift sling and linen from a bed underneath the resident on 7/26/24. Resident 1 sustained two lacerations on the scalp, one on the right side of the head and another on the front of the head and the right arm skin tear. On 7/26/24 at 12:15 p.m., Resident 1 was transferred to a GACH, where the resident underwent suturing of lacerations and was admitted to the GACH's telemetry unit for further evaluation and treatment. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.