Other·May 2, 2023

42 CFR § 483.25(d) Accidents The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; (2) and each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 3/20/2023 indicating on 3/18/2023, during a Hoyer lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places) transfer with a certified nursing assistant (CNA 1) and a resident (Resident 1), the sling hood piece hit the resident in the eye. The FRI indicated Resident 1 was sent out to a hospital and returned the same day with a diagnosis of corneal abrasion (a superficial scratch on the clear, protective “window” at the front of the eye [cornea]). On 3/31/2023, CDPH conducted an unannounced investigation at the facility. The facility failed to ensure CNA 1 provided care and services to prevent an injury to Resident 1’s left eye. The facility failed to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when using a Hoyer Lift to transfer Resident 1 from Resident 1’s bed to the wheelchair. 2. Ensure CNA 1 used the Hoyer lift according to the manufacturer’s instructions, indicating to use a two-person assistance for transferring a person to a wheelchair “with one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair.” As a result, CNA 1 transferred Resident 1 to the wheelchair on her own, without assistance, and the Hoyer lift hit Resident 1 in the left eye. Resident 1 was transferred to the general acute care hospital (GACH) due to the injury sustained to the left eye and was diagnosed with a corneal abrasion. During a review of Resident 1’s Admission Record (face sheet), the face sheet indicated Resident 1, was a 59 year-old male, originally admitted to the facility on 8/24/2018, and was readmitted on 10/22/2022, with diagnoses including glaucoma (a group of eye conditions that can cause blindness. The nerve connecting the eye to the brain was damaged, usually due to high eye pressure), type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), difficulty in walking, and muscle weakness. During a review of Resident 1’s History and Physical (H&P), dated 10/29/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/3/2023, the MDS indicated Resident 1 had the capacity to understand and be understood. The MDS indicated Resident 1 had total dependence for transfers out of bed and required two-person physical assistance. During a review of Resident 1’s Progress Note, dated 3/18/2023, at 10:12 a.m., the note indicated at 9:45 a.m., the Charge Nurse reported Resident 1 was hit by the Hoyer lift and the resident was bleeding in the left eye. The note indicated Resident 1 was assessed and noted with a bloodshot left eye, with bloody tears coming out from it. The note indicated the facility's Medical Director was notified and ordered to transfer the resident to the hospital. During a review of CNA 1’s written statement, dated 3/18/2023, the date of the incident, the statement indicated CNA 1 transferred Resident 1 to the wheelchair using the mechanical lift without the assistance of another staff member. During a review of CNA 1’s Disciplinary Action Notice, dated 3/18/2023, the notice indicated, “During patient transfer, an injury occurred. Resident 1 was supposed to be 2-person assist; however, the resident was transferred by CNA 1 alone/without assistance from another CNA.” The disciplinary action notice was signed by CNA 1 on 3/18/2023. During a review of Resident 1’s “Resident Transfer and Referral Record”, dated 3/18/2023, the record indicated Resident 1 was transferred via ambulance to a GACH on 3/18/2023 for an injury to the left eye. During a review of Resident 1’s GACH “After Visit Summary”, dated 3/18/2023, the summary indicated Resident 1 was diagnosed with a corneal abrasion and decreased vision. During a review of Resident 1’s Follow-Up Investigation Report, dated 3/20/2023, the report indicated on 3/18/2023, an eye patch was applied to Resident 1’s left eye. The report indicated Resident 1 arrived from the GACH with a diagnosis of corneal abrasion related to injury. The report indicated the following physician’s orders: 1. Erythromycin Ophthalmic Ointment (used to treat bacterial infections of the eye) 5 milligrams per gram (mg/g, unit of measurement) instill 1 application in the left eye every 6 hours for 7 days. 2. Fluorometholone Ophthalmic Suspension 0.1% (used to treat eye conditions caused by inflammation [swelling]) instill 1 drop in the left eye every 4 hours for 10 days. 3. Follow-up appointment with ophthalmologist (eye doctor) on 3/21/2023 at 11 a.m. During an interview on 3/31/2023, at 11:51 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the supervisor on 3/18/2023, day shift. RN 1 stated Licensed Vocational Nurse (LVN) 1 reported CNA 1 used the Hoyer lift to transfer Resident 1 to the wheelchair and when CNA 1 moved the Hoyer lift away from the resident, Resident 1 leaned forward, and the cradle part of the lift hit the resident in the left eye. RN 1 stated Resident 1’s left eye sclera (the white outer layer of the eyeball) was blood red and had blood-tinged tears. RN 1 stated 911 (emergency services) was called and Resident 1 was transferred to the GACH via ambulance. During an interview on 3/31/2023, at 12:02 p.m., with LVN 1, LVN 1 stated on 3/18/2023, the Hoyer lift hit Resident 1 in the left eye, when CNA 1 transferred Resident 1 to the wheelchair. LVN 1 stated it was required to have two-staff assistance when transferring a resident with the Hoyer lift. LVN 1 stated CNA 1 had not stated she had asked another staff for assistance when she transferred Resident 1 to the wheelchair. During an interview on 3/31/2023, at 12:44 p.m., with CNA 2, CNA 2 stated she was caring for Resident 1 today, 3/31/2023. CNA 2 stated when she transferred Resident 1 from the bed to the wheelchair, she requested two to three staff for assistance to transfer the resident using the Hoyer lift for safety. During an interview on 3/31/2023, at 1:22 p.m., with CNA 3, CNA 3 stated CNA 1 had not asked her for assistance to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 3 stated when using the Hoyer lift, there should be at least two staff assisting for the safety of the resident and staff. During an interview on 3/31/2023, at 1:40 p.m., with CNA 5, CNA 5 stated CNA 1 had not asked her for help to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 5 stated a minimum of two staff must be used when using the Hoyer lift and three staff should assist if the resident was heavier. During an interview on 3/31/2023, at 2:07 p.m., with the Director of Staff Development (DSD), the DSD stated the Hoyer lift must be used with a minimum of two staff. The DSD stated one staff controlled the mechanical lift and the other staff was to guide the lift and ensure the resident was safe. The DSD stated she had interviewed CNA 1 over the telephone and stated the first thing CNA 1 stated she knew she was supposed to have another staff assist her when she transferred Resident 1 using the Hoyer lift. The DSD stated CNA 1 had not mentioned that she had asked anyone for help when she transferred Resident 1 to the wheelchair. The DSD stated Resident 1’s accident was preventable because CNA 1 should have had another staff assist her when she transferred Resident 1 to the wheelchair using the Hoyer lift. During an interview with Resident 1 on 3/31/2023, at 3 p.m., Resident 1 stated CNA 1 had transferred her from the bed to the wheelchair using the Hoyer lift without assistance from other staff. Resident 1 stated other staff had used the Hoyer lift and transferred her to the wheelchair by themselves, but this was the first time she got hurt. Resident 1 stated the Hoyer lift was not raised high enough and it moved and hit her in the left eye. Resident 1 stated it was very bad when the accident happened because the resident's eye was a very delicate area. Resident 1 stated she was very scared because her eye was all bloody and she was afraid she could lose her eye. During a telephone interview on 4/10/2023, at 12:10 p.m., with CNA 1, CNA 1 stated on 3/18/2023, she transferred Resident 1 to the wheelchair using the Hoyer lift by herself. CNA 1 stated when she was retracting the Hoyer lift, Resident 1 leaned forward while she adjusted her blouse, and the metal bar of the Hoyer lift grazed (slightly hit) the resident’s left eye. CNA 1 stated Resident 1’s left eye was bleeding a little bit and she went to get the Charge Nurse and the Supervisor to assess the resident. CNA 1 stated she was trained to use the Hoyer lift and was instructed to always have two-person assistance when transferring a resident, but she had transferred Resident 1 on her own. CNA 1 stated she did not remember if she had asked someone for assistance, but at the end of the day it was her fault because she should have had another staff member assist her. CNA 1 stated she was not thinking when she transferred Resident 1 on her own. CNA 1 stated it was a mistake that would not happen again. During a review of the facility’s assistive devices lesson plan, dated 3/20/2023, the plan indicated the sling lift/Hoyer lift must be used with two staff members. During a review of the manufacturer instructions for the battery powered patient lift user manual, dated 10/18/2018, the manual indicated manufacturer recommended two assistants be used for all lifting and transfers. The manual indicated for transferring to a wheelchair “ one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward.” During a review of the facility’s policy and procedure (P&P) titled, "Mechanical Lift Use," undated, the P&P indicated, “The mechanical lift shall be used according to the manufacturer’s instruction booklet.” During a review of the facility’s P&P titled, "Mechanical Lift (Hoyer Brand)," dated 7/2012, the P&P indicated, “It is the policy of this facility to move a resident who is totally dependent in transfer by a mechanical means for resident’s safety.” The P&P indicated the procedure must be performed by nursing assistants or licensed nurses who have been in-serviced on use of the device. The P&P indicated, as one person (First person) operates and maneuvers the lift, move lift slowly away from bed. (Second person should guide the sling.) …First person to lower the patient down SLOWLY, and the second person guides the resident into the chair. The facility failed to ensure CNA 1 provided care and services to prevent an injury to Resident 1’s left eye. The facility failed to: 1. Ensure CNA 1 provided two-person physical assistance when using a Hoyer Lift to transfer Resident 1 from Resident 1’s bed to the wheelchair. 2. Ensure CNA 1 used the Hoyer lift according to the manufacturer’s instructions, indicating to use a two-person assistance for transferring a person to a wheelchair “with one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair.” As a result, CNA 1 transferred Resident 1 to the wheelchair on her own, without assistance, and the Hoyer lift hit Resident 1 in the left eye. Resident 1 was transferred to the GACH due to the injury sustained to the left eye and was diagnosed with a corneal abrasion. These violations, 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.