Health inspection·September 26, 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. §72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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. On 8/14/2024, the California Department of Public Health (CDPH) received a complaint and a Facility Reported Incident (FRI) on 8/15/2024 indicating a resident (Resident 1's) right hip was swollen with redness and bruising. An X-ray was taken at the facility indicating Resident 1 sustained a right hip fracture (break in the bone). On 8/14/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and an FRI reporting an injury. Upon investigation the CDPH determined Resident 1, who required a two-person assistance for transfers, was transferred from her Geri-chair (a large, padded chair that is designed to help seniors with limited mobility) to her bed by a Certified Nursing Assistant (CNA 1) by himself without assistance. During the transfer CNA 1 heard a "popping" sound that he did not report to a charge nurse. The facility failed to: 1. Ensure Resident 1, who was totally dependent on staff for care and required two-person physical assistance to complete activities of daily living ([ADL] task such as bathing, showering, dressing, transferring between surfaces including in and out of bed or a chair, walking, using the toilet, and eating), did not sustain an injury while being transferred from a Geri-chair to a bed. 2. Ensure CNA 1 did not transfer Resident 1 from a Geri-chair to a bed by himself without assistance from another staff in accordance with Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/7/2024 and Care Plan titled, "Self-Care Deficit" dated 6/3/2023. 3. Ensure CNA 1 reported to a licensed nurse when he heard a popping sound while transferring Resident 1 from a Geri-chair to a bed by himself. 4. Ensure staff followed the facility's policies and procedures (P&P) titled, a. "Certified Nursing Assistant (CNA)," which required CNAs to report changes in a resident's condition to a charge nurse and/or supervisor, b. "Safety and Supervision of Residents" which directed CNAs to implement interventions to reduce accidents, risks, and hazards, and c. "Body Mechanics," which directs CNAs to ask another staff member for assistance. As a result, Resident 1 sustained an acute comminuted displaced oblique fracture (the bone breaks into several pieces diagonally across the width of the bone) of the distal (the part of the body that is away from the center of the body than another part) right femoral (thigh bone) shaft (straight part of thigh bone), requiring Resident 1 to be transferred to a General Acute Care Hospital (GACH) on 8/13/2024. At the GACH Resident 1 underwent a retrograde intramedullary nailing (a metal rod is inserted into the center of the femur then fixed at both ends with screws) surgical procedure to the right femur to repair the fracture. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, was initially admitted to the facility on 3/23/2023 and readmitted on 5/21/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks) and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 1's MDS, dated 6/7/2024, indicated Resident 1's cognitive skills for daily decision making were moderately impaired (decisions were poor, cues/supervision required). The MDS indicated Resident 1 required dependent assistance (helper does all of the effort) from two or more staff for chair to bed/bed to chair transfers, rolling from left to and right, toileting and personal hygiene. A review of Resident 1's Care Plan titled, "Self-Care Deficit" revised 6/3/2023, indicated Resident 1 had self-care deficits with bed mobility, transfers, personal hygiene, bathing, and dressing. The Care Plan's goal indicated Resident 1's ADL needs would be met every shift. One of the Care Plan's interventions included to have a two-person assist for Resident 1's transfers and bed mobility. A review of Resident 1's Situation Background Assessment, and Recommendation ([SBAR] a form of communication between members of a health care team) communication form, dated 8/13/2024, indicated there was swelling above Resident 1's right knee and right posterior (back of ) thigh. The SBAR indicated Resident 1 had facial grimaces and moaning during repositioning. A review of Resident 1's Physician's Order Report dated 8/13/2024 and timed at 2 p.m., reflected an order to obtain a right hip and right knee X-ray due to swelling and to rule out a fracture. A review of Resident 1's right hip X-ray Report dated 8/13/2024, indicated Resident 1 sustained a right hip intertrochanteric fracture (a broken hip) with varus deformity (a condition that causes an abnormal position of the knee joint and lower leg bone). Resident 1's right knee X-ray Report indicated a distal femoral oblique fracture (a break in the thigh bone, or femur, that occurs just above the knee joint and has an angled line across the shaft). A review of Resident 1's Physician's Order Report dated 8/13/2024 and timed at 10 p.m. indicated to transfer Resident 1 to the GACH via paramedics. A review of the GACH's Emergency Department (ED) Provider Note dated 8/13/2024, indicated Resident 1 was admitted to the GACH ED on 8/13/2024, at 10:40 p.m. A review of the GACH's X-ray report dated on 8/13/2024, indicated Resident 1 sustained an acute comminuted displaced oblique fracture of the distal right femoral shaft. A review of the GACH's Surgical Case Report dated 8/17/2024, indicated Resident 1 underwent a retrograde intramedullary nailing of the right femur on 8/17/2024. During a telephone interview on 8/15/2024, at 9:44 a.m., Resident 1's Family Member (FM 3) stated she and FM 2 visited Resident 1 on 8/13/2024, around 11:20 a.m., and found Resident 1 grimacing in pain and noted her right thigh was "really" swollen. FM 3 stated they asked staff to assess Resident 1. During a telephone interview on 8/15/2024, at 11:20 a.m., and a subsequent interview at 3:09 p.m., CNA 1 stated on 8/13/2024 at approximately 10 a.m., Resident 1 was in her room sitting in a Geri-chair. CNA 1 stated Resident 1's diaper needed to be changed, so he pulled Resident 1 up from the Geri-chair to put her in bed so he could change her diaper. CNA 1 stated when he pulled Resident 1 up from the Geri-chair he heard a popping sound that "sounded like something hitting plastic." CNA 1 stated he looked around to see if he could figure out where the popping sound came from, but he could not find anything. CNA 1 stated at the time he heard the popping sound, he noticed that Resident 1 became more agitated than usual, but he did not pay much attention to it because Resident 1 had a behavior of being agitated during care. CNA 1 stated he transferred Resident 1 from the Geri-chair to the bed by himself without assistance from another staff because Resident 1's family was coming to visit her, and he wanted her to be ready before they (the family member) arrived. CNA 1 stated he knew Resident 1 needed a two-person assist with transfers, but he thought that was more for female CNAs, he was a guy, and it was not necessary for him to ask for help unless Resident 1 was combative or became irritable. CNA 1 stated it was probably better to have extra help when caring for Resident 1 and he should have asked someone to help him transfer the resident from the Geri-chair to the bed. CNA 1 stated he was a little concerned about Resident 1 when he heard the strange popping sound, so he waited with her until she calmed down and then left Resident 1's room. CNA 1 stated he did not report to anyone that he heard the popping sound when he transferred Resident 1. CNA 1 stated he later heard that Resident 1's hip was fractured and that was when he realized the popping sound he heard could have been when Resident 1's hip broke. CNA 1 stated he should have reported to a charge nurse the popping sound he heard when he transferred Resident 1 from the Geri-chair to the bed. During an interview on 8/15/2024, at 11:55 a.m., the Unit Manager (UM 1), a Licensed Vocational Nurse (LVN), stated Resident 1 required a two-person assist for transfers because Resident 1 was bed bound and totally dependent on staff for care and transfers. During a telephone interview on 8/15/2024, at 1:51 p.m., LVN 1 stated Resident 1 required two people to assist during her care, repositioning, and transfers, because she had a tendency of grabbing and holding onto staff's arms. LVN 1 stated during the morning huddle (a short nursing staff stand-up meeting in which residents care needs are reviewed and discussed) on 8/13/2024 at 6:45 a.m., they (nursing staff) were told Resident 1 needed a two-person assistance. LVN 1 stated CNA 1 did not report to her that he heard a popping sound while transferring Resident 1 from the Geri-chair to the bed. During a telephone interview on 8/15/2024, at 4:22 p.m., the Physical Therapist ([PT] a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) stated, Resident 1 required a two-person assist during transfers and care and to complete most of her ADLs, to be safe, and to prevent accidents and injuries, especially during transfers from a chair to a bed. During an interview on 8/15/2024, at 4:34 p.m., the Director of Staff Development (DSD) stated they (nursing staff) have shift huddles every morning at 6:45 a.m., where they discuss residents' safety during care. The DSD stated she mentions during every huddle that most of the residents require two people to assist during care for their safety. The DSD stated CNA 1 should have called for help from other staff when he provided care to Resident 1 to prevent any injury. The DSD stated CNA 1 should have reported to LVN 1 immediately after hearing a popping sound. During an interview on 8/15/2024, at 5 p.m., the Director of Nursing (DON) stated Resident 1's incident could have been avoided if CNA 1 had requested assistance to transfer Resident 1. The DON stated CNA 1 should have reported to a licensed nurse immediately after hearing a popping sound so Resident 1 could have been immediately assessed, avoiding any delay in the resident's care. A review of facility's P&P titled, "Safety and Supervision of Residents," revised 7/2017, indicated to implement interventions to reduce accident risks and hazards. A review of facility's undated P&P titled, "Body Mechanics," indicated to ask another staff member if you are going to need assistance. A review of the facility's undated P&P titled, "Certified Nursing Assistant (CNA)," indicated, to report changes in patient's condition to a charge nurse and/or supervisor. The facility failed to: 1. Ensure Resident 1, who was totally dependent on staff for care and required two-person physical assistance to complete ADL, did not sustain an injury while being transferred from a Geri-chair to a bed. 2. Ensure CNA 1 did not transfer Resident 1 from a Geri-chair to a bed by himself without assistance from another staff in accordance with Resident 1's MDS dated 6/7/2024 and Care Plan titled, "Self-Care Deficit" dated 6/3/2023. 3. Ensure CNA 1 reported to a licensed nurse when he heard a popping sound while transferring Resident 1 from a Geri-chair to a bed by himself. 4. Ensure staff followed the facility's P&P titled, a. "Certified Nursing Assistant (CNA)," which required CNAs to report changes in a resident's condition to a charge nurse and/or supervisor, b. "Safety and Supervision of Residents" which directed CNAs to implement interventions to reduce accidents, risks, and hazards, and c. "Body Mechanics," which directs CNAs to ask another staff member for assistance. As a result, Resident 1 sustained an acute comminuted displaced oblique fracture of the distal right femoral shaft, requiring Resident 1 to be transferred to a GACH on 8/13/2024. At the GACH Resident 1 underwent a retrograde intramedullary nailing surgical procedure to the right femur to repair the fracture. These failures resulted in violations of the above referenced regulations which jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. Therefore, an A citation is warranted.