Health inspection·June 7, 2024

42 CFR 483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72315 (e)- Nursing Service - Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 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. 22 CCR § 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: (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. 22 CCR § 72517- Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. . . . (5) Accident prevention and safety measures. On 4/25/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding an accident involving Resident 1 on 4/10/2024. As a result of the investigation, the CDPH determined Certified Nurse Assistants (CNAs) CNA 1 and CNA 2 failed to use the mechanical lift to transfer Resident 1, who was totally dependent on staff for transfers, and instead lifted Resident 1 by the armpits to stand the resident up from the wheelchair to change the resident’s incontinence brief, which caused the resident’s left shoulder to fracture (break in bone). The facility failed to: 1. Ensure CNA 1 and CNA 2 used a mechanical lift to raise Resident 1 from the wheelchair to change the resident’s incontinence brief. 2. Ensure CNA 1 and CNA 2 did not lift Resident 1 from a wheelchair by the resident’s armpits to stand and held the resident in a standing position to change the incontinence brief. 3. Ensure CNA 1 and CNA 2 followed the facility’s policy and procedure (P&P), titled “Patient lifting/Assisting Transfer Policy,” which indicated no resident lift or assisted transfers would be attempted without using a mechanical lift and two persons assistance to lift or transfer the resident. 4. Ensure CNA 1 and CNA 2 followed the facility’s P&P, titled “Use of Transfer Belts Policy,” which indicated that in the interest of safety and welfare to residents and staff all facility’s employees use transfer belts when lifting or transferring residents or use the appropriate lifting (mechanical) device. 5. Ensure CNA 1 and CNA 2 followed the facility’s P&P, titled “Procedure: Dressing Residents” which indicated precautions must be taken for residents who have problems with balance, and if the resident is not able to sit in a chair, dressing must be completed on the bed.” This deficient practice resulted in Resident 1 experienced severe pain and swelling of the left shoulder due to a left shoulder fracture and hospitalization at the general acute care hospital (GACH) for eight days where the resident received conservative treatment (avoidance of invasive [involving the introduction of instruments or other objects into the body] measures such as surgery or other invasive procedures) for the left shoulder fracture. Resident 1 developed severe shortness of breath and subsequently required intubation [a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe)]. A review of the Admission Record indicated Resident 1 was originally admitted to the facility on 7/4/2003, with diagnoses including amyotrophic lateral sclerosis (an abnormal hardening of a tissue or body part that occurs in several serious diseases), hemiplegia (paralysis that affects only one side of body) on the left non-dominant side and hemiplegia on the dominant right side, osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue), and a left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A review of the Resident 1’s History and Physical (H&P), dated 3/24/24, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 3/21/24, indicated the resident had an impairment on both sides of upper and lower extremities. The MDS indicated Resident 1 was dependent (unable to exert effort and totally reliant on external assistance) on facility staff with transfers, sit to stand, lower body dressing (the ability to dress and undress below the waist), eating, toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding, or having a bowel movement) personal hygiene, and bathing. A review of Resident 1’s untitled care plan, revised on 4/2/24, indicated the resident was at risk for spontaneous/pathological/stress fracture related to diagnosis of osteoporosis. One of the care plan interventions included to handle the resident gently and carefully during care. A review of Resident 1’s care plan, revised on 4/2/24, for Self-Care Deficits with Activities of Daily Living (ADL) indicated the resident was dependent on staff for toileting hygiene, lower body dressing. The care plan indicated Resident 4 had limited functions and impaired mobility related to hemiparesis and osteoporosis. The care plan indicated Resident 1 required a total assistance with ADLs. One of the care plan interventions was to provide Resident 1 with a safe environment. The care plan did not indicate what mobility devise would be used to assist with incontinence brief change and how the facility staff would utilize the mobility devise assistance. A review of Resident 1’s Licensed Nurses Note dated 4/10/24, indicated the resident needed two persons assistance for transferring and sit to stand (the ability come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). A review of Resident 1’s Medication Administration Record (MAR) for 4/1/24 to 4/30/24, indicated a physician order dated 6/13/22, to administer Tylenol (over the counter pain medication) 325 milligrams ([mg]-unit of weight measurement), two tablets every six hours as needed for pain management. The MAR indicated two tablets of Tylenol 325 mg were administered to Resident 1 on 4/10/24 at 2:35 PM for a pain level of 3 on a pain scale from zero to ten (where 0 indicated no pain and 10 indicated the most severe pain). A review of Resident 1’s Progress Notes dated 4/10/24 and timed at 2:35 PM, indicated two tablets of Tylenol 325 mg were administered to the resident for the left shoulder pain (no pan level indicated). The Progress Note indicated that at 3:07 PM, the pain medication administered to Resident 1 was ineffective. A review of Resident 1’s MAR for 4/1/24 to 4/30/24, indicated a physician order dated 4/10/24, to administer Tylenol 500 mg extra strength, two tablets twice a day for pain management. The MAR indicated two tablets of Tylenol 500 mg were administered to Resident 1 around 5 PM. The MAR did not indicate Resident 1’s pain level. A review of Resident 1’s MAR for 4/1/24 to 4/30/24, indicated a physician order dated 4/10/24, for Motrin (pain mediation) 200 mg tablet every six hours as needed for pain (pain level was not indicated). The MAR indicated one tablet of Motrin 200 mg was administered to Resident 1 at 6:20 PM, for a pain level of 8 out of 10 on a pain scale. A review of Patient 1’s Progress Notes dated 4/10/24 and timed at 5:13 PM, indicated Resident 1’s attending physician was notified of Resident 1’s left shoulder pain and ordered to transfer Resident 1 to the GACH for further evaluation. The Progress Note indicated Resident 1 was transferred to the GACH on 4/10/24 by ambulance at around 7:07 PM. A review Resident 1’s Progress Notes dated 4/11/24 and timed at 8:20 AM, indicated it was a Late Entry note. The Progress Note indicated Resident 1’s family member (FM 1) called ( date and time of FM 1 was unknown) the facility and the facility staff informed FM 1 that after Resident 1’s incontinence brief was changed; Resident 1 was placed back on the wheelchair and the resident hyperextended her arms while trying to make herself comfortable. The Progress Note indicated Resident 1 could have accidentally hurt herself. A review of Resident 1’s Order Summary Report for April 2024 indicated a physician order dated 4/10/24 (no time), to do STAT (with no delay) left shoulder X-ray (a photographic image of the internal composition of a body). A review of Resident 1’s X-ray Results Report, dated 4/10/24, indicated the resident had probable acute left humeral (upper arm bone) neck (end of bone) fracture (break in a bone). The X-ray Report indicated there was soft tissue swelling, inferior (away from the head-end of the body) subluxation (a subset of shoulder instability, occurs when the shoulder joint partially dislocates) likely secondary to a subacromial (commonly located to the top and lateral side of the shoulder) effusion (an abnormal collection of fluid). A review of Resident 1’s MAR from 4/1/24 to 4/30/24, indicated a physician order dated 4/10/24, to apply iced compress to the resident’s left shoulder for 15 minutes every shift. A review of the Resident 1’s Order Summary Report for April 2024, indicated a physician’s order dated 4/10/24 (no time) to transfer the resident to a GACH for further evaluation of left shoulder discomfort, pain, and swelling. A review of the GACH Radiology Report dated 4/10/24 timed at 7:59 PM, indicated an X-ray of the resident’s left humerus was performed due to Resident 1’s left arm pain, status post (an event that the resident experienced previously) trauma. The GACH Radiology Report indicated Resident 1 had slightly displaced proximal left humeral fracture involving the bone head and neck. A review of the GACH’s Discharge Summary dated 4/18/24, indicated Resident 1 had severe left shoulder pain due to left humerus fracture. The GACH Discharge Summary indicated the recommendation of Orthopedics Consult was medical treatment since the resident had a complicated medical condition and was not a candidate for surgery. The GACH Discharge Summary indicated the resident was treated conservatively, however, developed severe shortness of breath, and subsequently required intubation. The GACH Discharge Summary indicated that after intubation, the resident was transferred to another facility for long term care, in stable condition. During an interview on 4/25/24 at 10:23 AM, CNA 1 stated she was working during the morning shift on 4/10/24 when Resident 1’s incontinence brief needed to be changed. CNA 1 stated Resident 1 required assistance of two persons for transfers. CNA 1 stated on 4/10/24 at around 2 PM Resident 1 was sitting on the wheelchair in her room. CNA 1 stated that both CNA 2 and her (CNA 1) grabbed Resident 1 by the armpits and assisted Resident 1 to stand up on her feet. CNA 1 stated she grabbed the resident’s left armpit and left arm while she cleaned Resident 1’s buttocks using her (CNA 1’s) right hand. CNA 1 stated that CNA 2 was on Resident 1’s right side, while holding the resident by the right armpit. CNA 1 stated the whole cleaning and changing of Resident 1’s incontinence brief occurred in less than one minute. CNA 1 stated Resident 1 was held up in standing position less than one minute. CNA 1 stated Resident 1 did not complain of pain during that time. CNA 1 stated she and CNA 2 placed Resident 1 back on the wheelchair after an incontinence brief was replaced. CNA 1 stated Resident 1 complained of pain of the left shoulder as soon as Resident 1 sat back down on the wheelchair. CNA 1 stated that CNA 2 and her (CNA 1) did not use the mechanical lift or gait belt when Resident 1 was assisted to stand up during cleaning and changing the incontinence brief. On 4/25/24 at 1:54 PM during an interview the Occupational Therapist (OT 1) stated the facility staff should use a mechanical lift to transfer dependent residents. OT 1 stated that the appropriate way to assist dependent residents was to use the mechanical lift. OT 1 stated it was not appropriate to hold or grab Patient 1’s armpits to stand up the resident from the wheelchair. OT 1 stated that another appropriate way to assist the patient was to use a gait belt. OT 1 stated the residents with diagnosis of amyotrophic lateral sclerosis, osteoporosis, and cancer possessed bones that were more fragile and needed to be handled more carefully. OT 1 stated holding on to the armpits to stand up a resident from the wheelchair can risk causing a fracture. On 4/25/24 at 3:17 PM during an interview the Director of Staff Development (DSD) stated that residents, who were dependent on staff for activities of daily living, needed to be assisted with transfers using two persons and the mechanical lift or use a gait belt. The DSD stated CNA 1 and CNA 2 had to change Resident 1 in bed and for that they would need to transfer Resident 1 from a wheelchair to the bed. During a telephone interview with FM 1 on 4/25/24 at 3:31 PM, FM 1 stated Resident 1 was still at the GACH and complained about the same level of pain in her left fractured shoulder. A review of the facility’s P&P, titled “Use of Transfer Belts Policy,” (undated), indicated in the interest of safety and welfare to residents and staff, it is the facility’s policy that all facility employees use transfer belts when transferring residents or use the appropriate lifting device. A review of the facility’s P&P, titled “Patient lifting/ Assisting Transfer Policy,” updated 2/26/14 indicated, “No patient lift or assisted transfers will be attempted without using a [mechanical lift]. Use of mechanical lift requires at least two persons.” A review of the facility’s P&P, titled “Procedure: Dressing,” (undated), indicated for residents, who have problems with balance, precautions must be taken. If the resident is not able to sit in a chair, dressing can be completed on the bed. The facility failed to: 1. Ensure CNA 1 and CNA 2 used a mechanical lift to raise Resident 1 from the wheelchair to change the resident’s incontinence brief. 2. Ensure CNA 1 and CNA 2 did not lift Resident 1 from a wheelchair by the resident’s armpits to stand and held the resident in a standing position to change the incontinence brief. 3. Ensure CNA 1 and CNA 2 followed the facility’s policy and procedure (P&P), titled “Patient lifting/Assisting Transfer Policy,” which indicated no resident lift or assisted transfers would be attempted without using a mechanical lift and two persons assistance to lift or transfer the resident. 4. Ensure CNA 1 and CNA 2 followed the facility’s P&P, titled “Use of Transfer Belts Policy,” which indicated that in the interest of safety and welfare to residents and staff all facility’s employees use transfer belts when lifting or transferring residents or use the appro