Health inspection·September 13, 2024

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 72311. 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. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 8/5/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint and a facility reported incident regarding quality of care, resident safety, and falls. As a result of the investigation, the CDPH determined the facility failed to provide care and services to prevent a fall for Resident 1 by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided two-person physical to transfer Resident 1 from the bed to the shower chair when CNA 1 used the Hoyer lift (a mechanical device used by staff to lift and transfer residents from a bed to a chair or one location to another). 2. Ensure CNA 1 followed the facility’s policy and procedure (P&P) titled, “Total Mechanical Lift," dated 10/1/2023 when CNA 1 transferred Resident 1 with the Hoyer lift/mechanical lift. These violations resulted in Resident 1’s fall from the shower chair to the floor when CNA 1 removed the Hoyer lift strap from Resident 1’s left shoulder on 7/20/2024, at 11:30 a.m. Resident 1 sustained a laceration to the right frontal (forehead) area of Resident 1’s head. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 7/20/2024 at 12:20 p.m. for further evaluation and had a right frontal head laceration repair with three sutures. A review of Resident 1's Admission Record (AR) indicated, the facility originally admitted Resident 1, a 76-year-old female, on 12/6/2022, and readmitted Resident 1 on 4/12/2024, with diagnoses including type 2 diabetes mellitus, urinary tract infection, hemiplegia, and hemiparesis following cerebral infarction. A review of Resident 1’s untitled Care Plan (CP) initiated on 11/11/2023 indicated, Resident 1 was at risk for falls related to lack of coordination, hemiplegia, and dementia. The CP interventions included for staff to anticipate and meet Resident 1’s needs and educate Resident 1 and caregivers about safety reminders and what to do when a fall occurred. A review of Resident 1’s Fall Risk Assessment (FRA) dated 4/12/2024 indicated, Resident 1 was at high risk for falls due to total dependence on staff for activities of daily living and need for two or more persons physical assistance with bed mobility and transfer. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/2/2024 indicated, Resident 1 had moderately impaired cognition. The MDS indicated, Resident 1 was dependent on staff for toileting hygiene, showering/bathing, and upper and lower body dressing. The MDS indicated, Resident 1 was dependent on staff for chair/bed-to-chair transfers and tub/shower transfer. A review of Resident 1’s Progress Notes (PN) dated 7/20/2024, timed at 11:30 a.m. indicated, on 7/20/2024, at 11:30 a.m., CNA 1 was lowering Resident 1 from the Hoyer lift to the shower chair when Resident 1 bumped the right frontal area of Resident 1’s head on the doorknob of Resident 1’s bathroom. The PN indicated, Resident 1 sustained a “small” laceration and started bleeding. The PN indicated, Registered Nurse (RN) 1 called 911 and Resident 1 was transferred to GACH 1 for further evaluation. A review of Resident 1’s GACH 1 Emergency Department Narrative (ED Narrative) dated 7/20/2024, timed at 12:45 p.m. indicated, Resident 1 was brought in by emergency medical services from the facility for evaluation of a head injury after a mechanical fall. The ED Narrative indicated, Resident 1 experienced a fall while being transferred by nursing staff (CNA 1) resulting in a one (1) centimeter (cm) laceration on Resident 1’s head. The ED Narrative indicated, Resident 1’s wound was a linear horizontal laceration on the right frontal area of the head. The ED Narrative indicated, the wound was closed with three sutures. A review of Resident 1’s GACH 1 Computed Tomography Scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) Report of Resident 1’s head dated 7/20/2024, timed at 2:27 p.m. indicated, Resident 1 had a hematoma on the right frontal scalp of Resident 1’s head. A review of CNA 1's Corrective Action Memo (Memo) dated 7/25/2024 indicated, CNA 1 did not follow directions for two-person physical assistance for Hoyer lift transfer which resulted in Resident 1 being injured. During an interview on 8/5/2024 at 10:16 a.m., RN 1 stated on 7/20/2024, during the day shift (7 a.m. to 3 p.m. shift), the day Resident 1 fell, a staff member (unable to identify), notified RN 1 that RN 1’s assistance was needed in Resident 1’s room. RN 1 stated when RN 1 arrived in Resident 1’s room, Resident 1 was lying on the floor and bleeding from the right side of Resident 1’s head. RN 1 stated RN 1 called 911 immediately then the paramedics arrived and transferred Resident 1 to GACH 1. RN 1 stated Resident 1 returned to the facility after 3 hours with sutures on the right (frontal) area of Resident 1’s head. RN 1 stated CNA 1 had been using the Hoyer lift to transfer Resident 1 to the shower chair with two-person physical assistance in the past. RN 1 stated on 7/20/2024, (at 11:30 a.m.), CNA 1 used the Hoyer lift on Resident 1 without assistance from another staff member. RN 1 stated two staff members needed to be present and assisting “always” when using the Hoyer lift to transfer Resident 1 and any resident in general. During an interview on 8/5/2024 at 10:46 a.m., the Director of Rehabilitation (DOR) stated Resident 1 had been in the facility for a long time. The DOR stated Resident 1 was completely dependent on staff and always required the use of the Hoyer lift for transfers. The DOR stated two-person physical assistance was always required when using the Hoyer lift to transfer Resident 1. The DOR stated the first staff member operated the Hoyer lift while the second staff member maintained the resident’s (Resident 1’s) stability during and after the transfer. The DOR stated there was a risk for the Hoyer lift to tip over, or the sling holding Resident 1 could break when only one staff member used the Hoyer lift to transfer Resident 1. During an interview on 8/5/2024 at 11 a.m., the Director of Staff Development (DSD) stated the facility used a buddy system (an arrangement in which individuals are paired or teamed up) that provided a two-person team when operating the Hoyer lift to transfer residents. The DSD stated the CNAs (all CNAs) were aware that the CNA who covered the other CNA’s break time was also the CNA who would assist when transferring a resident (in general) with the Hoyer lift. The DSD stated Hoyer lift transfers required two staff members to be present always. The DSD stated the first staff member operated the Hoyer lift while the second staff member guided the resident during and after the transfer to ensure the resident was safe. During a concurrent observation and interview on 8/5/2024 at 1 p.m., in Resident 1’s room, Resident 1 was lying in Resident 1’s bed with the head of the bed elevated. There was a thin line on the right side of Resident 1’s head near the hair line with no visible sutures. Resident 1 stated Resident 1 could not move or get out of the bed by herself. Resident 1 stated the facility staff (CNAs) used a machine (Hoyer lift) to get Resident 1 out of the bed. Resident 1 stated CNA 1 was using the machine when Resident 1 fell from the (shower) chair (on 7/20/2024 at 11:30 a.m.). Resident 1 stated CNA 1 was using the machine by herself (CNA 1) when Resident 1 fell. Resident 1 stated she experienced “some pain (unable to rate and describe pain)” on her back when Resident 1 fell. During a telephone interview on 8/5/2024 at 1:20 p.m., CNA 1 stated on 7/20/2024, at 11:30 a.m., CNA 1 used the Hoyer lift to transfer Resident 1 in the shower chair. CNA 1 stated after CNA 1 transferred and placed Resident 1 in the shower chair using the Hoyer lift, CNA 1 began to remove the Hoyer lift sling from underneath Resident 1’s legs. CNA 1 stated while CNA 1 was removing the Hoyer lift straps from behind Resident 1’s left shoulder, Resident 1 fell from the shower chair to the floor and hit Resident 1’s head on the doorknob of Resident 1’s bathroom door. CNA 1 stated CNA 1 transferred Resident 1 from the bed to the shower chair with the Hoyer lift without assistance from another CNA. CNA 1 stated Resident 1 probably would not have fallen when two CNAs were operating the Hoyer lift during the transfer of Resident 1. During an interview on 8/5/2024 at 2:05 p.m., the Treatment Nurse (TN) stated on 7/20/2024, unable to recall time, the TN responded to Resident 1’s room to assist Resident 1 after Resident 1 fell. The TN stated Resident 1 had a laceration on the right (frontal) side of Resident 1’s head. The TN stated the TN was unable to measure Resident 1’s laceration right after the fall because of the amount of blood coming from the laceration. The TN stated the TN applied pressure to Resident 1’s head laceration until the paramedics arrived at the facility. The TN stated Resident 1 had sutures on Resident 1’s head when Resident 1 returned from GACH 1 (on 7/20/2024 at 3:41 p.m.). During an interview on 8/5/2024 at 2:43 p.m., the Director of Nursing (DON) stated Resident 1 was at the facility for at least two years and always required total care. The DON stated Resident 1 “always” needed a Hoyer lift during transfers. The DON stated CNA 1 admitted that CNA 1 “messed up (mishandle a situation)” when CNA 1 transferred Resident 1 from the bed to the shower chair using the Hoyer lift without assistance from another CNA. A review of the facility’s P&P titled, “Total Mechanical Lift," dated 10/1/2023 indicated, “A mechanical lift is used appropriately to facilitate transfers of residents.” The P&P indicated, “At least two people are present while resident is being transferred with the mechanical lift.” The facility failed to provide care and services to prevent a fall for Resident 1 by failing to: 1. Ensure CNA 1 provided two-person physical assistance to transfer Resident 1 from the bed to the shower chair when CNA 1 used the Hoyer lift. 2. Ensure CNA 1 followed the facility’s P&P titled, “Total Mechanical Lift," dated 10/1/2023 when CNA 1 transferred Resident 1 with the Hoyer lift/mechanical lift. These violations resulted in Resident 1’s fall from the shower chair to the floor when CNA 1 removed the Hoyer lift strap from Resident 1’s left shoulder on 7/20/2024, at 11:30 a.m. Resident 1 sustained a laceration to the right frontal area of Resident 1’s head. Resident 1 was transferred to GACH 1 on 7/20/2024 at 12:20 p.m. for further evaluation and had a right frontal head laceration repair with three sutures. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.