Health inspection·April 5, 2024

§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. On 2/7/2024 the California Department of Health (CDPH) received a complaint alleging a resident (Resident 1) was sat up by a nurse on the right side of her bed during care and Resident 1 fell and hit her head. On 2/22/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined Resident 1 was not safely assisted by Certified Nursing Assistant 2 (CNA 2) during incontinence care (cleaning the skin with mild soapy water, rinsing well, and patting the skin dry after an episode of uncontrolled urine and bowel movement) when CNA 2 suddenly snatched and pulled Resident 1's draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress, often used by medical professional to move patients) and rolled Resident 1 without warning and/or giving Resident 1 instructions. The facility failed to: 1. Ensure CNA 2 informed Resident 1 of her (CNA 2) intention to pull the resident's draw sheet and roll the resident on side while providing Resident 1 with incontinence care. 2. Ensure CNA 2 followed Resident 1's care plan and encouraged the resident to participate during provision of incontinence care by providing the resident with an explanation of the task prior to pulling the resident's draw sheet and rolling the resident in bed. 3. Ensure CNA 2 provided Resident 1 with supervision and assistance during provision of incontinence care to prevent an accident in accordance with the facility's policy and procedure (P/P) titled, "Safety and Supervision of Residents." As a result of this deficient practice Resident 1 fell from her bed hitting her head and knee on the floor thus placing Resident 1 at risk to sustain injuries. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 3/26/2012 with diagnoses including diabetes mellitus ([DM] a serious condition where the blood glucose [sugar] is too high) and atrial fibrillation (an irregular, often rapid heart rate). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/15/2024, indicated Resident 1 was able to make independent decisions that were reasonable and consistent, was able to understand and be understood by others, and had no difficulty with hearing. The MDS indicated Resident 1 was dependent on staff for toileting hygiene and required substantial/maximal (helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half of the effort) assistance rolling left to right and was incontinent (involuntary voiding of urine and stool) in both bladder and bowel functions. A review of Resident 1's Fall Risk Assessment dated 1/15/2024, indicated a score of 13 (total score of 10 or above represents high risk). A review of Resident 1's Care Plan dated 1/15/2024, indicated Resident 1 required assistance with activities of daily living (ADL). The Care Plan's goal indicated Resident 1 would maintain her current level of ADL participation with interventions that included encouraging her participation by providing cues and an explanation of tasks prior to performing them and assisting her with transfers by requesting extra help as needed. A review of Resident 1's Physician's Order dated 10/14/2023, indicated Resident 1 was receiving Apixaban ([Eliquis] an anticoagulant medication used to treat and prevent blood clots with a side effect of bleeding) 5 milligrams ([mg] a unit of measurement) two times daily for atrial fibrillation. A review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team) Communication Form dated 2/7/2024 and timed at 10 a.m., indicated Resident 1 had a fall episode when she rolled over and fell from her bed. During an interview on 2/22/2024 at 12:15 p.m., Resident 1 stated she was assisted by CNA 2 during perineal care (cleaning of the private area) when without warning or giving her instructions, CNA 2 suddenly snatched and pulled the draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress, often used by medical professional to move patients) and rolled her (Resident 1) towards the right side of the bed. Resident 1 stated she landed on the floor facing up and hit her head and left knee on the floor. Resident 1 stated CNA 2 should have warned her when she was about to turn her, so she could have held onto the side of the bed or the headboard to stabilize herself. Resident 1 stated she was shocked and scared for her life. During a telephone interview on 2/22/2024 at 2p.m., CNA 2 stated she was providing perineal care to Resident 1 and when she (CNA 2) turned Resident 1 to her right side, Resident 1 tumbled off the bed. During an interview on 2/22/2024 at 2:48 p.m., CNA 3 stated Resident 1 understands and follows cues and directions, but it was difficult for Resident 1 to turn or reposition in bed without assistance. During an interview on 2/22/2024 at 4:10 p.m., the Director of Nursing (DON) stated it was the nursing staff responsibility to make sure residents were safe when providing care. The DON stated Resident 1 was at risk for bleeding and bruising due to the blood thinner that she was taking. A review of the facility's undated P/P titled, "Repositioning" the P/P indicated the facility nursing staff should encourage the residents to participate in turning and/or repositioning to a comfortable position. A review of the facility's undated P/P titled, "Safety and Supervision of Residents," the P/P indicated the facility ensures supervision and assistance are provided to the residents to prevent accidents. The facility failed to: 1. Ensure CNA 2 informed Resident 1 of her (CNA 2) intention to pull the resident's draw sheet and roll the resident on side while providing Resident 1 with incontinence care. 2. Ensure CNA 2 followed Resident 1's care plan and encouraged the resident to participate during provision of incontinence care by providing the resident with an explanation of the task prior to pulling the resident's draw sheet and rolling the resident in bed. 3. Ensure CNA 2 provided Resident 1 with supervision and assistance during provision of incontinence care to prevent an accident in accordance with the facility's policy and procedure (P/P) titled, "Safety and Supervision of Residents." As a result of this deficient practice Resident 1 fell from her bed hitting her head and knee on the floor thus placing Resident 1 at risk to sustain injuries. This violation presented a direct or immediate relationship to the health, safety, or security of Resident 1. Long Beach Care Center Inc CA00883975 "B" Citation