Other·May 9, 2024

42 CFR § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 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 3/26/2024, during a standard annual Recertification Survey and facility reported incident investigation the California Department of Public Health (CDPH) identified the facility did not provide Resident 32 with a safe environment in the facility's van while the resident was riding to a medical appointment. Based upon observation, interview, and record review, the facility failed to: 1. Ensure Driver 1 secured Resident 32's upper body with a shoulder seat belt strap, when the resident was in a wheelchair, while being transported to and from a medical appointment in the facility's van. Driver 1 abruptly stopped the van while transporting Resident 32, causing the resident to suffer injuries when she was flip forward and the wheelchair to land on top of the resident. 2. Ensure the facility's policy and procedure (P&P) titled, Wheelchair Securement" had a shoulder sit belt use as a part of the safety system for a resident who is riding in the van while in a wheelchair. As a result, Resident 32 was thrown forward with a wheelchair landing on top of the resident when Driver 1 abruptly stopped the vehicle at a yellow light. Resident 32 was admitted to a general acute care hospital (GACH) on 3/19/2024 and hospitalized for six days with multiple fractures (broken bone) including fracture to both arms, both legs and neck. On 3/27/2024, Resident 32 was sent back to the GACH for anxiety related to the accident on 3/19/2024. A review of Resident 32's Admission Record, indicated Resident 32 is a 53 year old female, who was admitted to the facility on 7/3/2016 and readmitted on 2/21/2024 with diagnoses including right femur (thigh bone) pathological fracture (a break in a bone that happens without the force of an impact), age-related osteoporosis (causes bones to become weak and brittle), fibromyalgia (a chronic condition that causes pain in muscles and soft tissue all over the body), and dorsalis (back pain). A review of Resident 32's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 3/9/2024, indicated Resident 32 had the ability to understand others and the ability to express wants and thoughts. The MDS indicated Resident 32 was dependent on staff for toileting, showering, dressing, sitting, lying, and rolling from left to right. The MDS indicated Resident 32 required moderate assistance from staff with washing the face and combing the hair. The MDS indicated Resident 32 required setup and clean up assistance from staff with eating. The MDS indicated Resident 32 did not attempt to walk prior to current illness and did not attempt to use the wheelchair due to medical condition and safety. During a concurrent observation and interview on 3/26/2024 at 11:29 a.m. with Resident 32, the resident was observed to have splints (a removable device that temporarily immobilizes a joint after injury) on both legs wrapped with ace wrap bandages (a compression bandage, a long strip of stretchable cloth that can wrap around) and a cervical collar on her neck. Resident 32 was observed receiving physical therapy (therapy used to preserve, enhance, or restore movement and physical function). During the interview Resident 32 started crying, stated when she was coming back from a doctor's appointment, in the facility's van, she was not strapped in well and when Driver 1 abruptly stopped at a yellow light she flipped forward, and the wheelchair landed on top of her. Resident 32 stated she was on the van's floor for 30 minutes. Resident 32 stated she was wearing a lap belt strap but not the shoulder strap. Resident 32 stated she came to the facility to get better and get assistance and she ended up getting hurt. During an interview on 3/28/2024 at 9:59 a.m. a Certified Nursing Assistant (CNA 4) stated Resident 32 called her on 3/19/2024 to inform her she was admitted to the GACH due to the accident that happened on 3/19/2024 at 7 p.m. instead of going back to the facility after her doctor's appointment. CNA 4 stated Driver 1 made an abrupt stop at a yellow light causing Resident 32 to be thrown over from her wheelchair and was on her knees for 30 minutes. CNA 4 stated Resident 32 told her she was going to be admitted to the hospital for broken legs and broken neck. CNA 4 stated Resident 32 currently needed two-persons assistance for bathing, dressing, toileting, and transfer between surfaces, and care must be very slow because Resident 32 was in a lot of pain. During an interview on 3/28/2024 at 10:15 a.m. the Licensed Vocational Nurse (LVN 1) stated on 3/19/2024 during the evening shift (3 p.m. to 11 p.m.) Resident 32 was riding in the facility van returning from a doctor's appointment when Driver 1 had an abrupt stop, Resident 32 flew from her wheelchair and the wheelchair landed on top of the resident. LVN 1 stated as a result Resident 32 sustained a fracture on both legs and neck. LVN 1 stated Resident 32 now use a cervical collar and has the splints on both legs wrapped with ace bandages. During an interview on 3/29/2024 at 10:10 a.m. the Assistant Director of Nursing (ADON), stated on 3/19/2024 Resident 32 had an accident while being transported from her doctor's appointment by a van back to the facility and was sent to the GACH for further evaluation. The ADON stated that Resident 32 sustained the following fractures: 1. A displaced fracture (when the bone breaks into two or more parts and moves out of alignment) of fifth (5th) cervical (the neck region of the spine) spine. 2. A displaced fracture of the femur non-displaced fracture of the right tibia (shin bone). 3. A fractured shaft of the right fibula (leg bone on the lateral side of the tibia). 4. A fracture to the upper and lower left fibula. 5. A non-displaced fracture (a force causes a bone to crack or break but maintains its alignment) of the left tibia tuberosity (bony part on the upper part of the shin [front part of the leg]). 6. A fracture of the right and left humerus (the long bone in the arm that runs from the shoulder to the elbow). 7. A fracture of left femur. 8. A fracture of the right rib. The ADON also stated Resident 32 has a hard cervical collar brace (a medical device used to support and immobilize the neck) which she must wear while out of bed and soft cervical collar brace to wear while in bed. The ADON stated that Resident 32 has splints on the left and right leg and a care plan for non-weight bearing activity (physical exercise or movement that do not put any pressure or load on the joints) on the lower extremities. During an interview on 3/29/2024 at 11:02 a.m., Driver 1 stated on 3/19/2023 at 5 p.m. he went to pick up Resident 32 from the doctor's appointment. Driver 1 stated he parked the van, pulled down the ramp, pushed Resident 32 up the ramp, and positioned the wheelchair facing the front of the vehicle. Driver 1 stated he put the wheelchair on breaks and connected the wheelchair straps of the vehicle to the frame, then created tension using tensioner (device used for maintaining tension) and connected both back straps and front straps to the frame of the vehicle and connected resident 32's lap seatbelt. Driver 1 stated he was driving 45 miles per hour and when the traffic light turned yellow, he abruptly stepped on the brakes, resulting in Resident 32's wheelchair tipping over. Driver 1 stated when coming to a stop he heard Resident 32 yelling and calling for help as her wheelchair had tipped over and she was on the floor. Driver 1 stated Resident 32 was on the floor of the van still connected to wheelchair on top of her yelling and crying. Driver 1 stated the wheelchair was on top of Resident 32, so he unhooked the straps and unhooked her seatbelt then disconnected the wheelchair. Driver 1 stated he sat Resident 32 up and a bystander called 911. Driver 1 stated the paramedics arrived within 10 minutes and when Resident 32 was on the gurney he noticed Resident 32's left leg was dislocated. Driver 1 stated the facility has started implementing shoulder straps after the accident. Driver 1 stated he was not trained to use the shoulder straps during transport of the residents. Driver 1 stated he has never used the shoulder strap available in the van. Driver 1 stated the shoulder strap could have prevented Resident 32 from being thrown forward, especially during sudden or abrupt stops. Driver 1 stated the shoulder strap was an extra safety precaution and would have secured Resident 32's upper body. During an interview on 3/29/2024 at 11:49 a.m. The vehicle inspection technician (Tech 1) stated he inspected the facility van on 3/21/2024 and recommended to replace the straps used to secure the wheelchairs. Tech 1 stated the straps were beginning to wear out and there were newer updated straps and updated models. Tech 1 stated the facility followed the recommendation and purchased new straps that were installed on 3/21/2024, after Resident 32's accident on 3/19/2024. During an interview on 3/29/2024 at 12:28 p.m. the Director of Nursing (DON) stated Resident 32 fell forward while sitting in the wheelchair coming back from an appointment with Resident 32's medical doctor on 3/19/2024. DON stated Resident 32 was admitted to the facility on 7/3/2016 with a pathological fracture and after the accident Resident 32 sustained more fractures to the cervical spine, femur, humerus, tibia, and scapula (shoulder blade). During an interview on 3/29/2024 at 1:42 p.m. the Administrator (ADMN)stated he received a text message on 3/20/2024 from the housekeeping supervisor about Resident 32 being transported to the hospital due to the accident on 3/19/2024. The ADMN stated when Driver 1 stopped at the yellow light Resident 32's wheelchair tipped forward. The ADMN stated Resident 32 only had a lap strap on. Driver 1 was not able to get Resident 32 back in the wheelchair. ADMN stated a vehicle inspection was done on 3/21/2024 after the accident and followed Tech 1 recommendations to upgrade and replace all the straps in the facility's transportation van. ADMN stated the shoulder straps were implemented after the accident to give additional support and more added safety. A review of Resident 32's GACH records titled, "History and Physical" (H&P), dated 3/19/2024 indicated Resident 32 presented to the emergency department with complaints of pain in the arm, legs, and back after a fall in a transportation van. The H&P indicated Resident 32 was in her wheelchair in a transport van when the van stopped abruptly, and she fell forward with her wheelchair. Resident 32 was found to have multiple fractures including cervical thoracic spine fracture, bilateral tibia fibula fractures (broken bones in the lower leg), bilateral humeral neck fracture (broken bone in the upper arm), displaced left femur fracture, left elbow fracture, left and right shoulder fracture. A review of Resident 32's GACH records titled, "Neurosurgery Consult" dated 3/20/2024, indicated Resident 32 had a diagnosis of osteoporosis and came to the emergency room after not being strapped into a vehicle and falling, hitting her face. A review of Resident 32's GACH records titled, "Physical Therapy Screen", dated 3/22/2024, indicated Resident 32's plan of care was no surgical intervention, soft collar while in bed, hard collar when out of bed for eight weeks, pain control, physical therapy, and occupational therapy (health care provider who helps resident learn or regain skills of activities of daily living) evaluations. A review of Resident 32's GACH records titled, "Physical Therapy Consult", dated 3/23/2024, indicated Resident 32 "may benefit from bilateral knee immobilizers to stabilize her legs...and non-weight bearing activity to both lower extremities." A review of Resident 32's Nurses Progress Notes, dated 3/27/2024 at 8:42 a.m., the Nursing Progress Notes indicated, Resident 32 was requesting Ativan (medication used to treat anxiety) for anxiety and verbalizing being anxious. The Nursing Progress Notes indicated Resident 32 received a one-time order for Ativan 0.5 milligrams ([mg]- unit of measurement) for anxiety. A review of Resident 32's Nurses Progress Notes, dated 3/27/2024 at 8:57 a.m., the Nursing Progress Notes indicated, Resident 32 verbalized feeling anxious and nauseated related to the recent car accident. The Nurses Progress Notes indicated Resident 32 had a physician's order to receive a psychiatric evaluation and Hydroxyzine (medication used to treat anxiety and nausea) 25 mg every 12 hours for anxiety and Zofran (medication to treat nausea and vomiting) 4.0 mg every six hours as needed for nausea. A review of the facility's vehicle Inspection Invoice (from a company that specializes in servicing wheelchair vans), dated 3/21/2024, the vehicle Inspection Invoice indicated, a recommendation for replacing the old straps with the latest version of straps. A review of the facility's Investigation Report titled, "Final Investigation of Unusual Occurrence", undated, the Investigation Report (IR) indicated, a recommendation was made to upgrade the securing straps to the latest version. The IR indicated the new straps were purchased at that time. The IR indicated, "as a measure of increased security to prevent an incident such as this from occurring in the future an additional shoulder restraint seat belt will be used when securing a patient in the van." A review of facility's P&P titled, "Wheelchair Securement", revised 12/2021 indicated residents must be secured in their wheelchair and secured in the vehicle before any movements of the vehicle or transportation of any kind was to occur. Most all passenger transportation vehicles will have a securement system. According to the manufacturer recommendations for a wheelchair securements and occupant restraints for transporting individual website article, (undated) "Always secure the occupant in the vehicle with a complete Occupant Restraint System, consisting of lap and shoulder belts. Secure the wheelchair in the vehicle with a Wheelchair Tie-Down System." https://sure-lok.com/products/occupant-restraints/ A review of the facility's job description for drivers titled, "Job Description: Driver," revised on 10/2017, the driver job description indicated, "the primary purpose of your job position is to transport residents to and from appointments and activities in a safe and courteous manner...Secure passengers 'wheelchairs to restraining devices to stabilize wheelchairs during trip." The facility failed to: 1. Ensure Driver 1 secured Resident 32's upper body with a shoulder seat belt strap, when the resident was in a wheelchair, while being transported to a medical appointment in the facility's van. Driver 1 abruptly stop the van while transporting Resident 32, causing the resident to flip forward and the wheelchair to land on top of the resident. The failure resulted in Resident 32 suffering injuries from their failure to ensure Resident 32 was properly transferred based on the policies and procedures. 2. Ensure the facility's P&P titled, "Wheelchair Securement" had a shoulder sit belt use as a part of the safety system for a resident who is riding in the van while in a wheelchair. As a result, Resident 32 was thrown forward with a wheelchair landing on top of the resident when Driver 1 abruptly stopped the vehicle on a yellow light. Resident 32 was admitted to a GACH on 3/19/2024 and hospitalized for six days with multiple fractures including fracture to both arms, both legs and neck. On 3/27/2024 Resident 32 was sent back to the GACH for anxiety related to the accident on 3/19/2024. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 32.