Health inspection·March 16, 2023

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 1/5/2023 at 11:30 am, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a Facility Reported Incident regarding quality of care and fall (unintentionally coming to rest on a lower-level surface) of Patient 1. As a result of the investigation, The CDPH determined the facility failed to provide Patient 1 with necessary care and services to prevent a fall by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance (help from two person) when using a Hoyer Lift (mechanical lift, a device used by staff to transfer patients from a bed to a chair or other similar places) to transfer Patient 1 from Patient 1's bed to the Geri chair (large, padded chair with wheeled bases, and are designed to assist seniors with limited mobility/ability to move) per the facility's policy and procedure (P&P) titled, "Hoyer Lift." 2. Ensure CNA 1 notified Licensed Vocational 3 (LVN 3) to place Patient 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump designed to circulate a constant flow of air) on an auto firm mode (set in place and unable or unlikely to move), before CNA 1 turned Patient 1 to the right side of the bed to place the Hoyer lift net/sling (flexible strap used to support or raise the patient) under Patient 1 while the patient was lying on the LAL mattress per the facility's P&P on "Safety and Supervision of Patients," and the Manufacturer's Operations Manual, titled "Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress." As a result of these failures, on 12/19/2022 at 8:45 am, Patient 1 fell from the LAL mattress. The facility transferred Patient 1 to a General Acute Care Hospital (GACH) Emergency Department (ED) via ambulance. Resident 1 sustained a left frontal (forehead) scalp (skin on the top of the head where hair grows) hematoma (collection of blood), periorbital (pertaining to or surrounding the eye) swelling, bilateral (both) nasal (nose) bone fracture (broken bone), and an acute (immediate) nondisplaced (bones broken but the pieces were not moved far enough) transverse fracture (bone is broken perpendicular to its length) through the patella (kneecap). Patient 1 experienced pain (not rated) on her left knee. A review of Patient 1's Admission Record indicated the facility admitted Patient 1, a 69 years old female on 7/4/1998 and readmitted the resident on 9/1/2022, with diagnoses including aphasia (a disorder that affects how you communicate), hemiplegia (paralysis on one side of the body), and hemiparesis (inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting the right side of the body. A review of Patient 1's History and Physical, dated 9/7/2022, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's Care Plan titled, "Risk for Fall and Injury," revised on 9/26/2022, indicated for nursing staff to minimize falls and injuries by assisting Patient 1 in all transfers and mobility and use Hoyer lift with 2-person assist during transfer. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2022, indicated Patient 1 had moderately impaired (poor decisions, cues/supervision required) cognitive (ability to think and process information) skills for decision making. The MDS indicated Patient 1 was totally dependent (full staff performance) with two or more persons physical assist for transfer (how the patient moves between surfaces including to or from: bed, chair, wheelchair or standing position). A review of Patient 1's Fall Risk Assessment, dated 12/8/2022, indicated Patient 1 was at high risk for falls due to Patient 1’s visual impairment (eyesight is reduced), balance problems with sitting and ambulation (ability to walk). A review of Patient 1's Situation, Background, Assessment, Recommendation (SBAR) Form, dated 12/19/2022, timed at 2 pm, indicated on 12/19/2022 at 8:45 am, CNA 1 reported to Licensed LVN 3 that Patient 1 was on the floor. The SBAR indicated Patient 1 rolled off Patient 1's bed during morning care. The SBAR indicated LVN 3 found Patient 1 lying on the floor beside Patient 1's bed, facing up with blood flowing from the patient's face. The SBAR indicated Patient 1 had blood noted around and underneath the patient's head. The SBAR indicated Patient 1 had an abrasion (area damaged by scraping/wearing away) on the left knee, and discoloration (changing color in a bad way) on the left eye. Patient 1's nose had 0.8 centimeters (cm-unit of measurement) by 0.2 cm open wound with bleeding and Patient 1's left knee had 1.2 cm by 1 cm abrasion. The SBAR indicated Patient 1 moaned (made a long, low sound expressing physical or mental suffering) and cried. The SBAR indicated LVN 3 notified Patient 1's Primary Physician/Medical Doctor 1 (MD 1) and MD 1 recommended to transfer Patient 1 to a GACH ED for further evaluation. A review of Patient 1's Licensed Nurse Progress Notes, dated 12/19/2022, indicated on 12/19/2022 at around 8:45 am, CNA 1 called LVN 3 to Patient 1's room to report a fall. The notes indicated LVN 3 found Patient 1 lying on the floor with blood on the patient's face. The notes indicated Patient 1 had a skin tear to the patient's nasal bridge (the upper, bony part of the human nose), bleeding from the lower lip, an abrasion to the left knee, and a raised area on Patient 1's left forehead. The notes indicated the facility transferred Patient 1 to the GACH ED, at 12:40 pm, via ambulance. A review of Patient 1's GACH Facial Bones Computed Tomography (CT, a procedure that uses a computer linked to a machine to make a series of detailed pictures of areas inside the body) Report, dated 12/19/2022 at 2:27 pm, indicated Patient 1 fell from the bed, hit her face on the floor, and sustained moderate left frontal scalp hematoma, periorbital swelling, bilateral nasal bone fracture with mild displacement (moving away from the normal location/position). A review of Patient 1's GACH Left Knee X-ray (pictures of the inside of the body) Report, dated 12/19/2022 at 5:37 pm, indicated Patient 1 sustained an acute nondisplaced transverse fracture through the patella. A review of Patient 1's GACH ED Visit Summary, dated 12/19/2022, indicated for Patient 1 to follow-up with Head and Neck Surgery and Orthopedist (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints) as an outpatient (a patient who receives medical treatment without being admitted to a hospital) in three days, and to take clindamycin (an antibiotic medicine) three times a day for 10 days. A review of Patient 1's Licensed Nurse Progress Notes, dated 12/19/2022 at 10:30 pm, indicated Patient 1 returned to the facility from the GACH ED. A review of the facility's Investigation Report, dated 12/19/2022, indicated CNA 1 was putting the Hoyer lift's net under Patient 1, and Patient 1's LALM "slightly slide side off the bed." The report indicated CNA 1 was unable to keep Patient 1 from rolling and falling off the bed. Patient 1 fell on her face, and CNA 1 yelled for help. A review of Patient 1's Physician Follow Up Progress Note, dated 12/20/2022 at 10:37 pm, indicated Patient 1 had bilateral (both) periorbital ecchymosis (discoloration of skin resulting from bleeding), both nares (nostrils) patent with dried blood. The note indicated Patient 1 groaned (made deep sound in response to pain or despair) in pain to light touch on the left knee. Patient 1's left knee had an immobilizer (a device used to support and protect a broken bone or injury). During an interview with Registered Nurse Manager (RN 1) on 1/5/2023 at 12:05 pm, RN 1 stated, LVN 3 notified her on 12/19/2022 at 8:45 am, that Patient 1 fell and was on the floor. RN 1 stated she immediately went to Patient 1's room and Patient 1's LALM's setting was on. RN 1 stated LVNs were responsible for the setting of the LALM. RN 1 stated the LALM settings needed to be paused while CNA 1 provided care for Patient 1 when the patient was lying in the bed for safety. RN 1 stated CNAs could not change, turn on/off the LALM's settings. During an interview with CNA 2 on 1/5/2023 at 1:20 pm, CNA 2 stated on 12/19/2022, he was the assigned Restorative Nurse Assistant (RNA- helps patients to maintain their function and joint mobility) for the facility. CNA 2 stated CNA 1 did not ask him for assistance to transfer Patient 1 via the Hoyer lift. CNA 2 stated it was the responsibility of the LVNs to change the LALM's settings. During an interview with LVN 1 on 1/5/2023 at 1:30 pm, LVN 1 stated Patient 1's LALM should be on static/pause mode while CNA 1 was changing or moving Patient 1 so that LALM or Patient 1 did not slip or fall off the bed. LVN 1 stated she could not remember when she was in-serviced (training and education) "maybe two years ago," on the use of LALM. During an interview with CNA 1, on 1/5/2023 at 2:25 pm, CNA 1 stated on 12/19/2023, she assisted Patient 1 with morning care. CNA 1 stated she was standing on Patient 1's left side and rolled the patient onto the patient's right side while the patient was lying on the bed. CNA 1 stated while Patient 1 was on the patient's right side, CNA 1 placed the Hoyer lift's net/sling under Patient 1 and rolled the patient back on the patient's left side. CNA 1 stated she remained on Patient 1's left side while attempting to place Patient 1 on the Hoyer lift net/sling. CNA 1 stated she was not sure if the LALM was secured to the bedframe. CNA 1 stated she heard a "humming," sound coming from the LALM. CNA 1 stated the mattress deflated (having been emptied of air or gas,) the head of the LALM had a bubble, the foot of the LALM was flat, and Patient 1 slid off the LALM and fell to the floor. CNA 1 stated CNAs were not supposed to touch the LALM controls/settings. CNA 1 stated she was not sure if the LALM should be turned on or off while she was providing care to Patient 1. CNA 1 stated she did not ask anyone to turn the LALM's settings off while turning Patient 1 in bed. CNA 1 stated she did not remember if she received any in-services for the use of the LALM. During an interview with Registered Nurse 2 (RN 2) on 1/5/2023 at 4:41 pm, RN 2 stated CNAs could not operate the LALM controls/settings. RN 2 stated CNAs needed to inform LVNs when changing or moving a patient in bed on a LALM to prevent accidents and to keep the patients safe. During an interview with RN 1 on 1/5/2023 at 4:50 pm, RN 1 stated LVNs and CNAs did not receive in-services on the use of the LALM. A review of the facility's Policy and Procedure titled, "Safety and Supervision of Patients," revised in July 2017, indicated the facility strives to make the environment as free from accidents hazards as possible. Patient safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazard and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. A review of the facility's Policy and Procedure titled, "Hoyer Lift," dated October 2003, indicated the use of the Hoyer lift will be performed by at least two nursing assistants with the maximum use of safety principles. A review of the undated Manufacturer's Operations Manual titled, "Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress," submitted by the facility, indicated for nursing staff to read the manual in its entirety before using the product. Turning the "power" switch "on/off" will start/stop the control unit. The switch lights up when the power is "on," and extinguishes when the power is "off". Press the "auto-firm," button to set auto-firm mode to quickly inflate the air mattress to the maximum pressure which facilitates nursing and caring. The auto-firm indicator lights up (amber) when the system is in auto-firm mode. The system will automatically return to the previous mode 30 minutes after the auto-firm mode is in operation. It is also possible to cancel auto-firm mode by pressing the auto-firm button. As a result of the investigation, The CDPH determined the facility failed to provide care and services to prevent a fall for Patient 1 by failing to: 1. Ensure CNA 1 provided two-person physical assistance when using a Hoyer Lift to transfer Patient 1 from Patient 1's bed to the Geri chair per the facility's P&P titled, "Hoyer Lift." 2. Ensure CNA 1 notified LVN 3 to place Patient 1's Low Air Loss mattress on an auto firm mode, before CNA 1 turned Patient 1 to the right side of the bed to place the Hoyer lift net/sling under Patient 1 while the patient was lying on the LAL mattress per the facility's P&P on "Safety and Supervision of Patients," and the Manufacturer's Operations Manual, titled "Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress." As a result of these failures, on 12/19/2022 at 8:45 am, Patient 1 fell from the LAL mattress. The facility transferred Patient 1 to a GACH-ED via ambulance. Resident 1 sustained a left frontal scalp hematoma, periorbital swelling, bilateral nasal bone fracture and an acute nondisplaced transverse fracture through the patella. Patient 1 experienced pain on her left knee. The above violations 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.