Health inspection·February 3, 2025

F689 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 1/3/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident safety. As a result of the investigation, the facility failed to provide a safe environment for Resident 1 by failing to ensure the Maintenance Director (TMD) had a schedule of maintenance services for Resident 1’s bed remote control coil line and Certified Nurse Assistant 2 (CNA 2) prevented Resident 1 from grabbing onto Resident 1’s damaged/broken bed remote control coil hanging on Resident 1’s right bed side rail during care. As a result, on 12/17/2024 at 5 am, Resident 1 sustained a laceration on Resident 1’s inner right hand between the thumb and index finger measuring 2 centimeters (cm) in length, by 0.2 cm in width and by 0.2 in depth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 12/17/2024 at 10:45 am and required seven surgical sutures for wound closure. Resident 1 had six stitches along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, an 83-year-old male on 8/29/2024 with diagnoses that included type II Diabetes Mellitus, heart failure and respiratory failure. A review of Resident 1’s History and Physical (H&P) dated 9/17/2024 indicated Resident 1 was non-verbal and did not have the capacity to make medical decisions. A review of Resident 1’s Minimum Data Set (MDS) dated 12/3/2024 indicated Resident 1 had unclear speech and severely impaired cognition. The MDS indicated Resident 1 was dependent for toileting, showering, dressing and chair/bed-to-chair transfers. A review of Resident 1’s Progress Notes (PN) dated 12/17/2024, timed at 5 am indicated Resident 1 sustained an inner right-hand cut/laceration when Resident 1 held onto the right bed side rail while being cleaned and turned by CNA 2. A review of Resident 1’s PN dated 12/17/2024, timed at 5:46 am indicated Resident 1 had an open cut/wound on the inner right hand. The PN indicated Resident 1’s right hand wound was acquired in the facility and measured 2 cm in length by 0.2 cm in width and 0.2 cm in depth. A review of Resident 1’s Physician’s Order (PO) dated 12/17/2024 (untimed) indicated to transfer Resident 1 to GACH 1 due to “right hand cut.” A review of Resident 1’s PN dated 12/17/2024, timed at 10:45 am indicated Resident 1 was transferred to GACH 1 due to a cut on the right hand. A review of GACH 1’s Emergency Department Note (EDN) dated 12/17/2024 indicated Resident 1 had a right-hand laceration and received laceration repair. The EDN indicated Resident 1’s right hand laceration was closed with seven stitches. A review of Resident 1’s PN dated 12/17/2024, timed at 6:20 pm indicated Resident 1 was readmitted back to the facility from GACH 1 after treatment of Resident 1’s laceration to the right palm of the hand. The PN indicated Resident 1 had six stitches along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear. During an observation of Resident 1’s right hand in Resident 1’s room on 1/3/2025 at 11:24 am, Resident 1 was lying in bed with eyes closed. Resident 1’s right hand was wrapped with dry bandage roll. During an observation of Resident 1’s right palm, in Resident 1’s room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 1/3/2025 at 11:29 am, Resident 1’s right palm had seven stitches between the thumb and the index finger. LVN 1 stated, Resident 1 was sent to GACH 1 on 12/17/2024 due to a cut to the right hand from Resident 1’s bed remote control coil line. LVN 1 stated, the outer hard plastic layer of Resident 1’s bed remote control coil line was broken, and part of the coil was pointing out. LVN 1 stated, when CNA 2 turned and repositioned Resident 1, Resident 1 grabbed onto the sharp broken part of the bed remote control coil line, and Resident 1 sustained a laceration of Resident 1’s right hand/palm. LVN 1 stated, staff need to ensure Resident 1’s equipment was in good condition to prevent injury to Resident 1. LVN 1 stated, maintenance staff need to routinely check all devices and equipment to ensure the equipment and devices were in good condition and working properly for resident’s safety. During an interview with the Maintenance Assistant (MA) on 1/3/2025 at 12 pm, the MA stated, the MA did an investigation on 12/17/2024 after Resident 1 sustained a right-hand laceration. The MA stated, Resident 1’s bed remote control coil line was broken. The MA stated the inside of the electric wire was exposed, and the outer layer/hard plastic was peeled off, forming a sharp pointed edge. The MA stated, there was blood stain on the broken part of Resident 1’s bed remote control coil. The MA stated, checking the bed remote control was not part of the Maintenance Department’s routine task since MA started working at the facility nine months ago and the Maintenance Department would only check the bed remote control upon request. The MA stated, checking the bed remote control was added to the Maintenance Department’s routine task after the incident with Resident 1, who sustained a laceration of the inner right hand on 12/17/2024. The MA stated it was important to check all resident’s equipment routinely including the bed remote control to ensure resident’s safety and to prevent injury to the residents. The MA stated, if the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1’s injury could have been prevented. A review of Resident 1’s Interdisciplinary Team (IDT) Progress Note dated 12/17/2024, timed at 2:27 pm, and an interview with the facility’s Director of Nursing (DON) on 1/3/2025 at 1:17 pm, the IDT Progress Note indicated on 12/17/2024 around 5 am, Resident 1 was being turned and changed by CNA 2 and CNA 2 saw Resident 1 holding onto the siderail on the right side of the bed with bloody open cut in the inner right hand between Resident 1’s thumb and index finger. The IDT Progress Note indicated Resident 1’s bed control coil line was “damaged with the hard plastic sticking out.” The DON stated Resident 1 grabbed onto Resident 1’s damaged/broken bed coil line and sustained an injury on Resident 1 right hand. The DON stated, it was important to routinely check all medical devices and equipment and to keep them in good condition for resident’s safety. The DON stated, Resident 1’s injury could be avoided if the facility maintained its equipment in good condition. During an interview with the facility’s Administrator (ADM) on 1/3/2025 at 3:01 pm, the ADM stated CNA 2 was terminated. The ADM and Surveyor 1 called CNA 2 for a telephone interview and CNA 2 did not answer the phone call. A review of the facility’s P&P titled, “Safe and Homelike Environment,” dated 12/19/2022 indicated “The facility will provide a safe, clean, comfortable, and homelike environment.” The P&P indicated “This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.” A review of the facility’s P&P titled, “Preventive Maintenance Program,” dated 12/19/2022 indicated “A preventive maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.” The P&P indicated “The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.” The facility failed to provide a safe environment for Resident 1 by failing to ensure the TMD had a schedule of maintenance services for Resident 1’s bed remote control coil line and CNA 2 prevented Resident 1 from grabbing onto Resident 1’s damaged/broken bed remote control coil hanging on Resident 1’s right bed side rail during care. As a result, on 12/17/2024 at 5 am, Resident 1 sustained a laceration on Resident 1’s inner right hand between the thumb and index finger measuring 2 cm in length, by 0.2 cm in width and by 0.2 in depth. Resident 1 was transferred to GACH 1 on 12/17/2024 at 10:45 am and required seven surgical sutures for wound closure. Resident 1 had six stitches along the right thumb with ragged edges and one stitch on the base of the index finger with skin tear. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.