Health inspection·December 24, 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(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. §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 11/25/2024 the California Department of Public Health (CDPH) received an anonymous complaint regarding resident care and verbal abuse. On 12/3/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. While investigating the complaint allegations, which were unsubstantiated, the CPDH was made aware of an unrelated incident regarding a resident (Resident 1) who sustained an injury to his left leg while being transferred from a wheelchair to his bed. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) asked another staff member to assist her with transferring Resident 1 from a wheelchair to his bed, per Resident 1's care plan titled, "Needs Assistance with Activities of Daily Living ([ADL] basic tasks that residents need to do to care for themselves such as eating, dressing and toileting ) revised 10/14/2024, which indicated Resident 1 required total assistance of two to three persons for transfers. 2. Ensure staff followed the facility's undated policy and procedure (P&P) titled, "Safe Resident Handling/Transfers" which indicated the residents should be handled and transferred safely to prevent or minimize risks of injury and to provide and promote a safe, secure, and comfortable experience for the resident. These failures resulted in Resident 1's left leg being caught on the wheel of a wheelchair and sustaining a laceration (a deep cut or tear in the skin) to the left posterior (back) of his lower leg, requiring ten sutures (a stitch or row of stitches holding together the edges of a wound). On 11/22/2024 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of his left leg laceration. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 74 year-old male, was admitted to the facility on 1/26/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness on one side of the body) following a cerebral infarction ([stroke] a medical condition that occurs when blood flow to the brain is disrupted) affecting Resident 1's left dominant (the side of the body or brain that is used more than the other side) side. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/14/2024, indicated Resident 1 had intact cognitive (ability to think, understand, learn, and remember) skills for daily decision-making. The MDS indicated Resident 1 was able to understand and was understood by others. The MDS indicated Resident 1 had impairment on both sides of his upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 1 used a wheelchair for mobility and needed partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) with chair/bed to chair transfers. A review of Resident 1's Transfer Form dated 11/22/2024 and timed at 11:30 p.m., indicated Resident 1 was transferred to a GACH on 11/22/2024 at 10:20 p.m., due to a skin wound (unspecified location). A review of the GACH's Emergency Department (ED) documentation dated 11/22/2024, indicated Resident 1 was brought to the emergency room (ER) due to a laceration to his left lower leg. The ED Documentation indicated Resident 1's left leg laceration was repaired using 10 sutures. During an interview on 12/4/2024 at 10:30 a.m., Resident 1 stated CNA 4 was assisting him to transfer from a wheelchair to his bed by lifting him using her arm under his armpit and holding his pants with her hand. Resident 1 stated when CNA 4 turned him towards the bed, his left leg got caught in the wheel of the wheelchair. Resident 1 stated his left leg was bleeding profusely (a large amount) and he was transferred to a GACH where he received sutures to his left leg. Resident 1 stated he required two people to assist him during transfers because his left leg was paralyzed (unable to move) and he was unable to fully support his body when moving from the wheelchair to the bed. During an interview on 12/5/2024 at 9:25 a.m., CNA 4 stated on 11/22/2024 at approximately 10 p.m., she transferred Resident 1 from a wheelchair to his bed. CNA 4 stated she held Resident 1 under his armpit with one hand and with another hand she held onto Resident 1's pants. CNA 4 stated as she was transferring Resident 1 to his bed, Resident 1's left leg got caught in the wheel of the wheelchair. CNA 4 stated she was not aware Resident 1 had a wound to his left leg until she removed his pants and saw his left leg was bleeding. CNA 4 stated Resident 1 should have been transferred using two people for safety because he had left sided paralysis. During a concurrent interview and record review on 12/5/2024 at 10:02 a.m., with Licensed Vocational Nurse (LVN 2), Resident 1's Care Plan, titled "Needs Assistance with ADLs" revised 10/14/2024 was reviewed. LVN 2 confirmed and stated the Care Plan indicated Resident 1 required total assistance with transfers and he should be transferred using two to three staff. During a concurrent interview and record review on 12/5/2024 at 10:46 a.m., with the MDS Coordinator (MDSC), Resident 1's MDS dated 10/14/2024 was reviewed. The MDS indicated Resident 1 had impairment on both sides of his upper and lower extremities. The MDSC stated it was not safe to transfer Resident 1 using only one person because Resident 1 had an impairment in both his upper and lower extremities. During a review of the facility's P&P tiled, "Safe Resident Handling/ Transfers" undated, the P&P indicated it was the policy of the facility to ensure that resident was handled and transferred safely to prevent or minimize risks for injury and provided and promote a safe, secure, and comfortable experience for the resident. During a review of the facility's P&P titled, "Safety and Supervision of Residents" undated, the P&P indicated "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The facility failed to: 1. Ensure CNA 4 asked another staff member to assist her with transferring Resident 1 from a wheelchair to his bed, per Resident 1's care plan titled, "Needs Assistance with Activities of Daily Living" revised 10/14/2024, which indicated Resident 1 required total assistance of two to three persons for transfers. 2. Ensure staff followed the facility's undated P&P titled, "Safe Resident Handling/Transfers" which indicated the residents should be handled and transferred safely to prevent or minimize risks of injury and to provide and promote a safe, secure, and comfortable experience for the resident. These failures resulted in Resident 1's left leg being caught on the wheel of a wheelchair and sustaining a laceration to the left posterior of his lower leg, requiring ten sutures. On 11/22/2024 Resident 1 was transferred to a GACH for evaluation and treatment of his left leg laceration. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 4.