Health inspection·March 2, 2023

F689 Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. (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. § 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. On 1/05/23 at 12:05 pm., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care and treatment of Patient 1. As a result of the investigation, CDPH determined the facility failed to provide care and services to prevent a fall for Patient 1 by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 provided two-person physical assistance (help from two persons) to transfer Patient 1 from the bed to a shower chair while using a Hoyer Lift (mechanical lift, a device used by staff to transfer patients from a bed to a chair or other similar places) per the facility’s Policy and Procedure (P&P) on “Total Mechanical Lift.” 2. Ensure CNA 1 and CNA 2 implemented strategies to reduce the risk of falls and use the Hoyer lift correctly to prevent a fall from the mechanical lift per the facility's P&P on "Fall Management Program,” “How to Safely Lift a Patient into A Patient Lift/Hoyer Lift," and Resident 1’s care plan on “Safety.” As a result, on 12/21/2022, at 9:10 a.m., Patient 1 fell from the Hoyer Lift. Patient 1 suffered a laceration (deep cut to the skin) to the forehead and experienced severe generalized body pain and was transferred to a General Acute Care Hospital (GACH) Emergency Department (ED) via 911 (emergency services) and was found to have a fracture of the right kneecap (a flat movable bone forming the front part of the knee) and right lower leg. A review of Patient 1's Admission Record indicated the facility admitted Patient 1, a 70 year-old female, to the facility on 9/10/2021 with diagnoses including unspecified quadriplegia (paralysis that affects a person's limbs and body from the neck down), cerebral palsy (a physical disability which affects movement and posture), muscle weakness, abnormalities of gait (manner of walking or moving on foot), and mobility (ability to move). A review of Patient 1's Fall Risk Evaluation dated 9/10/2021, indicated Patient 1 was at risk for falls due to the patient being chairbound, had balance problems while standing, walking, decreased muscular coordination, and required the use of assistive devices (cane, wheelchair, walker, furniture). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/17/2021, indicated Patient 1's cognition (ability to think and process information) was severely impaired (significantly limited). The MDS indicated Patient 1 was totally dependent on two or more persons physical assist to transfer the patient from or to bed, chair, wheelchair. A review of Patient 1's Change in Condition Evaluation (COC) dated 12/21/2022, timed at 9:30 a.m., indicated on 12/21/2022, at 9:10 a.m., CNA 2 called Licensed Vocational Nurse 1 (LVN 1) to come to Patient 1's room. The COC indicated LVN 1 found CNA 1 with Patient 1 on the floor, underneath the Hoyer Lift. LVN 1 noted Patient 1's right side of the forehead was bleeding with a laceration. LVN 1 noted Patient 1 had discoloration (change in color in a bad way) and swelling of the right knee, and redness of right shoulder. Patient 1 complained of 8/10 (severe/intense) generalized body pain on a scale of 0-10 (0 means no pain, and 10 means the worst possible pain). Patient 1's Primary Physician (MD 1, Doctor of Medicine) was notified, and MD 1 ordered Patient 1's transfer to the GACH ED for further evaluation. A review of Patient 1's Facility to Hospital Transfer Form, dated 12/21/2022, timed at 9:15 a.m., indicated Patient 1 was transferred to a GACH ED via ambulance. A review of Patient 1's Progress Notes, dated 12/21/2022, timed at 11:13 a.m., indicated the facility transferred Patient 1 to the GACH due to a fall. A review of CNA 1's Interview Report, dated 12/21/2022, indicated CNA 2 lifted Patient 1 up on the Hoyer lift. The report indicated CNA 1 was by Patient 1's side (side not specified) and holding Patient 1 while CNA 2 was standing behind and maneuvering (moving skillfully or carefully) the Hoyer lift. The report indicated CNA 2 walked away from the Hoyer lift to get the shower chair and CNA 1 walked away from Patient 1's side to the back to maneuver the Hoyer Lift. Patient 1 started to cough, leaned forward, and fell off the Hoyer Lift. A review of Patient 1's GACH ED Provider Note, dated 12/21/2022, indicated the GACH ED Physician (MD 2) irrigated (cleansed/washed) and anesthetized (administered medication to prevent sensation or eliminate pain) on Patient 1's laceration on the right side of the forehead. MD 2 repaired the laceration with Vicryl sutures (sterile surgical threads used to repair cuts) and discussed Patient 1's case with the Orthopedic Physician (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints), who recommended to apply a splint (a rigid or flexible device that maintains in position a displaced or movable part) to prevent knee rotation (prevent movements of the knee to prevent further knee injury). A review of Patient 1's GACH X-ray (photographic or digital image of a body part) Report, dated 12/21/2022, indicated Patient 1 sustained an acute (severe and sudden onset) transverse (across) fracture (condition in which bones crack or break into pieces) of the lower patella (knee cap), acute oblique fracture (when the bone is broken at an angle) of proximal (nearer to the center of the body) tibial shaft (one of the bones of the lower leg), prepatellar (the front of the knee cap) and pretibial (the front of the large bone of the lower leg) edema (swelling), and severe osteopenia (when bones are weaker than normal). A review of Patient 1's GACH Orthopedic Physician Note, dated 12/23/2022, at 3:53 p.m., indicated Patient 1 may need a cast treatment (a protective shell of fiberglass, plastic, or plaster, and bandage that is molded to hold a fractured bone in place while it heals), versus surgical fixation (a surgical procedure that stabilizes and joins the ends of fractured bones by mechanical devices such as metal). During an observation of Patient 1 on 1/5/2023, at 1:19 p.m., Patient 1 was in the bed awake and alert. Patient 1's forehead had a reddish colored and healed dry laceration with one staple (a piece of thin wire to fasten an open wound) on the right side of the patient's forehead. Patient 1's right lower leg was covered with a bandage (a strip of material used to bind a wound or to protect an injured part of the body) in ace wrap dressing (elasticated bandage) and a splint. Patient 1's right lower leg was elevated on a pillow. During an interview with CNA 1 on 1/5/2023, at 2:06 p.m., CNA 1 stated on 12/21/2022, while Patient 1 was cradled (placed) in the sling (flexible strap used to support or raise the Patient) on the Hoyer Lift, CNA 1 maneuvered the Hoyer Lift and CNA 2 left the Hoyer Lift to move the shower chair closer to Patient 1. CNA 1 stated Patient 1 was coughing hard. CNA 1 stated Patient 1 tried to spit her saliva by leaning forward and Patient 1 fell. CNA 1 stated Patient 1 fell fast, and the patient’s face hit the floor. CNA 1 stated Patient 1's right side of the head was bleeding. CNA 1 stated she applied pressure on Patient 1's forehead while CNA 2 ran out of the room to notify the charge nurse (LVN 1). During an interview with CNA 2 on 1/5/2023, at 2:39 p.m., CNA 2 stated she left the patient while on the Hoyer Lift's sling and went to get the shower chair by the foot of Patient 1 roommate's bed next to Patient 1's bed. CNA 2 stated when she turned her back on Patient 1 and CNA 1, she heard Patient 1 coughed and CNA 1 screamed, "she fell." CNA 2 stated as she turned around, she saw Patient 1 on the floor. During an interview with CNA 2 on 1/25/2023, at 10:33 a.m., CNA 2 stated initially when Patient 1 was sitting on the Hoyer lift's sling, CNA 2 stood behind the Hoyer lift and maneuvered the lift. CNA 2 stated she left to get the shower chair located next to Patient 1’s roommate's bed. CNA 2 left CNA 1 by herself, standing next to Patient 1 while Patient 1 was on the Hoyer Lift sling. CNA 2 stated CNA 1 left Patient 1's side and walked behind to take control of the Hoyer Lift and prepared to position Patient 1 on to the shower chair. CNA 2 stated one staff (in general) should be at Patient 1's side, close to Patient 1 at all times while Patient 1 was on the Hoyer Lift sling to prevent accidents and falls. During an observation of Patient 1 in Patient 1's room on 1/25/2023, at 11:10 a.m., with CNA 2, Patient 1 was lying in bed, awake. Patient 1 had a laceration on the right side of the forehead with pinkish discoloration. Patient 1 had a splint on the right lower leg. Patient 1 complained of pain on her right foot. During a concurrent interview with LVN 1 on 1/25/2023, at 3:08 p.m. and a review of Patient 1's COC Evaluation, dated 12/21/22, LVN 1 stated there was "a lot" of bleeding on Patient 1's laceration on the right side of the forehead. LVN 1 stated Patient 1's right knee had swelling with pinkish discoloration and Patient 1 complained of pain. LVN 1 stated Patient 1 said, "I'm pain." A review of Patient 1's undated Care Plan, titled "Safety," indicated patient will remain safe. One of the interventions in the care plan indicated safety measures for the patient including for staff to implement strategies to reduce the risk of falls, injury as appropriate. A review of the facility's undated P&P, titled "Fall Management Program," indicated to provide patients a safe environment that minimizes complications associated with falls. The policy indicated the facility will implement a fall management program that supports providing an environment free of fall hazards. A review of the facility's undated P&P, titled "Total Mechanical Lift," indicated a mechanical lift is used appropriately to facilitate transfers of patients. The policy indicated at least two people are present while patient is being transferred with the mechanical lift. A review of the facility undated P&P, titled "How to Safely Lift A Patient Into A Patient Lift/Hoyer Lift," indicated for staff to know how to use the Hoyer lift correctly can prevent patient falls from lifts, which may cause injuries, including head trauma, fractures and death. As a result of the investigation, the Department determined the facility failed to provide care and services to prevent a fall for Patient 1 by failing to: 1. Ensure CNA 1 and CNA 2 provided two-person physical assistance to transfer Patient 1 from the bed to a shower chair while using a Hoyer Lift per the facility’s P&P on “Total Mechanical Lift.” 2. Ensure CNA 1 and CNA 2 implemented strategies to reduce the risk of fall and used the Hoyer lift correctly to prevent a fall from the mechanical lift per the facility's P&P on "Fall Management Program," and "How to Safely Lift a Patient into a Patient Lift/Hoyer Lift," and Resident 1’s care plan on “Safety.” As a result, on 12/21/2022, at 9:10 a.m., Patient 1 fell from the Hoyer Lift. Patient 1 suffered a laceration to the forehead and experienced severe generalized body pain and was transferred to a GACH ED via 911 and was found to have a fracture of the right kneecap and right lower leg. The above violations jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1.