Health inspection·January 19, 2024

42CFR §483.25: Free of Accident Hazards/Supervision/Devices §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: (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 §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 12/12/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Resident 1 did not fall off Resident 1’s Low Air Loss Mattress (LALM) while Certified Nursing Assistant 1 (CNA1) provided personal hygiene and incontinent care to Resident 1 in accordance with the facility’s policy and procedures titled “Fall Management Program” last revised on 3/13/2021 and “Safety of Residents” revised on 1/1/2012. 2. Ensure CNA 1 called a licensed nurse (LN) to pause or set the LALM to static before assisting Resident 1 with personal hygiene and incontinent care in accordance with the facility’s policy and procedures titled, “Fall Management Program” last revised on 3/13/2021 and “Safety of Residents” revised on 1/1/2012. 3. Ensure that CNA 1 was trained in the proper use of the LALM in accordance with the facility’s policy and procedure titled, “In-Service Training and Record Keeping” last revised one 2/20/2020 and the manufacturer’s recommendations. As a result, on 11/10/2023, at around 10 p.m., while CNA 1 was turning Resident 1 in bed without the LALM adjusted to firm, Resident 1 fell out of bed hitting the back of the head. Resident 1 was immediately transferred to General Acute Care Hospital 1 (GACH 1) and required three staples (specialized surgical staples used to close wounds) to a laceration (cut) on the scalp at the back of the head. A review of Resident 1’s Admission Record indicated the facility admitted the 82-year-old female Resident 1 on 4/6/2021 with diagnoses including right hemiplegia (loss of strength on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (a disruption of blood supply and oxygen to the brain), muscle wasting (loss of muscle tissue and strength), and cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think). A review of Resident 1’s Fall Risk Evaluation form, dated 6/25/2023, indicated Resident 1 scored 18. The assessment tool indicated that a score of ten (10) or higher meant high fall risk. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/5/2023, indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for care including bed mobility, transfers from or to bed, and showering or bathing. Resident 1 was assessed as incontinent (unable to control) of bowel and bladder functions. A review of the Physician’s Order for Resident 1, dated 6/26/2023, indicated the use of a LALM for skin management due to skin fragility (skin easily breaks) with normal pressure and to set firmness at Resident 1’s current weight. A review of Resident 1’s Treatment Administration Record (TAR) indicated that from 11/1/2023 to 11/10/2023, Resident 1 was using the LALM. A review of Resident 1’s Change in Condition, dated 11/10/2023, indicated that approximately at 10 p.m. CNA 1 reported he needed assistance because Resident 1 had fallen out of bed. Upon entering Resident 1’s room, Charge Nurse found Resident 1 on the floor on lying on the left side of the bed. Charge Nurse noticed blood on the ground and asked CNA 1 to call Registered Nurse (RN) Supervisor. RN Supervisor, after assessing Resident 1, instructed staff (unspecified) to call 911. Resident 1 was noted with blood on the back of the head, repeatedly calling out and crying, grimacing (expression of pain), and unable to be consoled or reassured. A review of the Physician’s Order for Resident 1, dated 11/10/2023, indicated to transfer Resident 1 to a GACH via 911 related to falling. A review of Resident 1’s GACH 1 History and Physical Reports, dated 11/11/2023, indicated Resident 1 had a laceration on the scalp and three staples. Resident 1 was admitted to GACH 1. On 12/7/2023 at 3:11 p.m., during an interview, the Treatment Nurse (TM) stated only licensed nurses (LNs, both Licensed Vocational Nurses [LVNs] and RNs) were allowed to change / adjust the LALM settings. TM stated the setting of the LALM is based on the resident’s weight. If the mattress was “placed on static or in paused mode before care was provided, the mattress would be same level of firmness; the resident would not be thrown off the mattress, the air inside would be static.” The TN did not mention the use of the Max Inflate / Low Air Loss Button. On 12/7/2023 at 3:32 p.m., during an interview, the Director of Staff Development (DSD) stated he did not know about the settings for the LALM for care and turning in bed or the purpose of the Static button on the LALM pump. The DSD indicated he was responsible for providing training to staff but confirmed that training related to use of LALM was not provided. The DSD did not provide evidence that nursing staff reviewed the LALM manufacturer’s recommendations and guidance on its use. On 12/7/2023 at 3:48 p.m., during an interview, the Quality Assurance (QA) Nurse stated that adjusting the LALM firmness for care was important when treatment or personal care was provided to the residents on the LALM so that the air pressure inside the mattress would equalize. The QA Nurse stated the LNs could stop the LALM air flowing by pressing the pause or the Static Button and this would keep the air inside the mattress even. The QA Nurse indicated that if the air inside the mattress was not even, the free-flowing air will not equalize the pressure inside the LALM, the weight of the resident on one side of the bed would flatten the mattress and cause the air to shift to the opposite side of the mattress and push the resident off. The QA Nurse added that the LALM material could be slippery. The QA Nurse did not mention the use of the Max Inflate / Low Air Loss Button. On 12/7/2023 at 4:08 p.m., during an interview, CNA 1 confirmed he took care of Resident 1 on 11/10/2023 when Resident 1 fell out of the bed. CNA 1 confirmed not calling a LN to pause or set the LALM to static before assisting Resident 1 with personal hygiene and incontinent care. CNA 1 stated he was at the right side of the bed when turning Resident 1 onto Resident 1’s left side and Resident 1 fell on the left side of the bed, the opposite side of the bed from where CNA 1 was standing. CNA 1 indicated seeing blood on the back area of Resident 1’s head. On 12/7/2023 at 5:11 p.m., during an interview, RN 2, when asked what the static button on an LALM was for, RN 2 stated, “I don’t know. I am not sure. I have not received in-service on use of LALM.” On 12/7/2023 at 6:18 p.m., during an interview, the QA Nurse stated the vendor (provide the facility with the LALM) have not provided in-service training to the nursing staff on the use of the LALM. The QA Nurse did not provide evidence nursing staff reviewed and were familiar with the LALM manufacturer’s recommendations and guidance on its use. On 12/7/2023 at 6:36 p.m., during interview, the Director of Nurses (DON) stated Resident 1 was at risk of infection on the scalp laceration. The DON was asked to provide a policy and procedure (P&P) on the use of the LALM including the settings and who was allowed to adjust the settings and when settings needed to be adjusted (i.e., providing personal care); however, none was provided. A review of the LAL Mattress Manufacturer’s General Guidelines, page 5 of 33, indicated, “Danger, Risk for Death, Injury or Damage:” - If you are unable to understand the warnings, cautions or instructions, contact healthcare professional, dealer, or technical personnel before attempting to use this equipment. - Do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals or instruction sheets supplied with this product or optional equipment.” The LAL Mattress Manufacturer’s General Guidelines, page 21 of 33, indicated, “Press the Static Button to enter Static mode and maintain all air cushions in the mattress at a constant pressure.” The LAL Mattress Manufacturer’s General Guidelines, page 22 of 33, indicated, “Press the Max Inflate / Low Air Loss button to select the max inflate mode or the low air loss mode. Max Inflate Mode: in this mode the mattress inflates rapidly to maximum firmness. It is recommended that Max Inflate setting be used during turning or patient cleaning.” A review of the facility’s provided P&P titled, “Fall Management Program,” last revised on 3/13/2021, indicated the purpose of the P&P was “To provide residents a safe environment that minimizes complications associated with falls.” A review of the facility’s provided P&P titled, “Safety of Residents,” revised on 1/1/2012, indicated the purpose of the P&P was “To provide a safe environment for residents and Facility Staff.” A review of the facility provided P&P titled, “In-Service Training and Record Keeping,” last revised one 2/20/2020, indicated the “Training program shall address specific needs of the facility’s resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.” As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Resident 1 did not fall off Resident 1’s LALM while CNA1 provided personal hygiene and incontinent care to Resident 1 in accordance with the facility’s policy and procedures titled, “Fall Management Program,” last revised on 3/13/2021 and “Safety of Residents” revised on 1/1/2012. 2. Ensure CNA 1 called a LN to pause or set the LALM to static before assisting Resident 1 with personal hygiene and incontinent care in accordance with the facility’s policy and procedures titled, “Fall Management Program,” last revised on 3/13/2021 and “Safety of Residents” revised on 1/1/2012. 3. Ensure that CNA 1 was trained in the proper use of the LALM in accordance with the facility’s policy and procedure titled, “In-Service Training and Record Keeping” last revised one 2/20/2020 and the manufacturer’s recommendations. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.