Other·December 4, 2020

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a Entity Reported Incident (ERI) investigation. ERI Intake Number: CA00703561 Representing the Department of Public Health: HFEN # 40178 and HFEN # 36356 The inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for ERI number CA00703561

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/13/2020 §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. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure two Certified 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Nurse Assistants (CNAs) transferred a resident from wheelchair to bed when using a mechanical lift (a device to transfer a person with a minimum of physical effort) to ensure a safe transfer for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling, bleeding from the left nostril, sustained a fracture (broken) of the right hip, and suffered right hip pain and left knee pain. Resident 1 was transferred to General Acute Care Hospital (GACH), where the resident underwent a right hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact). Findings: A review of Resident 1's Admission Record indicated, the facility admitted Resident 1, on 6/4/2015, with diagnoses including morbid obesity (over weight), functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord) and wheelchair (WC) dependence. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/16/2020, indicated the resident had no short-term memory problem. The MDS indicated Resident 1 was dependent on staff activities of daily living (ADL, bed mobility, surface transfer, locomotion on and off the unit, dressing and toilet use) and cannot walk. The MDS indicated Resident 1 required two or more persons physical assist with transfers between surfaces including to and from bed, chair, and wheel chair. A review of the facility's "EZ Way Smart Lift 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 500, 600 and 1,000 pounds (lbs) Capacities," revised 8/10/2018, the safety notes indicated the lift was designed to be operated safely according to facility policy, and patient's condition, two caregivers may be necessary. A review of the facility's "EZ Lift Check List," dated 11/29/2018, indicated CNA 3 did not lock the EZ lift wheels during operation demonstration. A review of Resident 1's ADL functional/Rehab Potential care plan, e-signed (electronic signature) on 7/24/20, indicated Resident 1 required a mechanical lift for transfers and needed two persons assist for safety. A review of Resident 1's Basic Needs and Preferences care plan, e-signed on 7/24/2010, indicated Resident 1 stated, "I need 2 persons to assist me with my transfers, and I am nonambulatory (not able to walk)." A review of Resident 1's Activities care plan, esigned on 7/24/2020, indicated the resident has potential for falls related to functional quadriplegia and abnormality of gait (manner of walking). A review of Resident 1's Interdisciplinary Notes, dated 8/31/2020 at 9:16 p.m., indicated that on 8/31/2020 at 4:15 p.m., CNA 3 called out that the resident fell. The resident was laying on her back on the floor and complained of right hip pain and left knee pain. Resident 1 was bleeding from the left nostril. A review of Resident 1's Physician Order, dated 8/31/2020, indicated the resident may transfer to the hospital via 911 (medical telephone emergency) for evaluation and treatment. 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE A review of Resident 1's General Acute Care Hospital (GACH) Emergency Department Reports, dated 8/31/2020 at 5:00 p.m., indicated the resident has a history of polio (a viral disease that can affect nerves and can lead to partial or full paralysis) with lower extremities paralysis (the loss of muscle function in part of your body). The report indicated the resident fell from a lift during a transfer from chair to bed, had an abrasion (open wound that's caused by the skin rubbing against a rough surface) to left hand, generalized muscle aches and symptoms acute (sudden) and severe prior to arrival. Resident 1 had tenderness to right hip area and was administered Tramadol (controlled medication used to relieve moderate to moderately severe pain) 50 milligrams (mg, measuring unit) on 8/31/2020 at 6:19 p.m. The resident was diagnosed with a right hip fracture, condition guarded (a life-threatening illness whose vital signs have been stabilized and is now wellsupported is still in danger). Resident 1 was admitted for surgery, on 8/31/2020 at 9:10 p.m. A review of Resident 1's GACH Surgery and Procedure Reports, dated 9/1/2020 at 4:38 p.m., indicated the resident had right closed femoral (thigh bone) neck fracture. Resident 1 was administered anesthesia (general or local insensibility, as to pain and other sensation, induced by certain interventions or drugs to permit the performance of surgery), intubated (placing a tube in your throat to help move air in and out of your lungs) and had a right hip hemiarthroplasty. A review of Resident 1's GACH Procedure Notes, dated 9/1/2020 at 5:59 p.m., the resident had central line (a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE do medical tests quickly) insertion procedure performed. Resident 1 was admitted to intensive care unit (ICU, a designated area of a hospital facility that is dedicated to the care of patients who are seriously ill). A review of Resident 1's GACH Discharge Summaries Notes, dated 9/8/2020, indicated the resident was discharged back to the facility. A review of Resident 1's Orthopedic Conditions care plan, e-signed on 9/9/2020, indicated Resident 1 was status post (S/P, after) right hip arthroplasty (the surgical reconstruction or replacement of a joint). During an observation and concurrent interview on 9/14/2020 at 1:10 p.m., Resident 1 was lying in bed. Resident 1 stated that she remembered she fell from the lift and did not recall what happened. The resident stated she had a broken hip and was transferred to the GACH. During an observation on 9/14/2020 at 1:30 p.m., two CNAs used a mechanical lift to transfer a non-sampled resident from a wheelchair (WC) to bed. On a concurrent interview, CNA 1 and CNA 2 both stated that per facility's policy, two staff were required to transfer a resident for safety when using a mechanical lift. During an interview on 9/14/2020 at 2:05 p.m., the Director of Nurses (DON) stated CNA 3 reported that Resident 1 wanted to go back to bed right away and other CNAs were busy and did not call for help to transfer the resident. The DON stated CNA 3 reported that the sling came off from the mechanical lift hook, and Resident 1 swung sideways and fell. The DON stated the mechanical lift was about two feet and five inches (2' 5") from the floor. The DON 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE stated two CNAs are required to operate a mechanical lift when transferring a resident. During an interview, on 9/14/2020 at 4:20 p.m., CNA 3 stated Resident 1 was alert and oriented. CNA 3 stated on 8/31/2020 at about 4:15 p.m., the Resident 1 wanted to go back to bed, was getting irritated and angry. CNA 3 stated it was the beginning of the shift; everyone was busy and could not find anyone to help transfer the resident. CNA 3 stated she brought the mechanical lift, placed Resident 1 on it and then Resident 1 started moving. CNA 3 stated the sling came loose from the mechanical lift hook and Resident 1 fell. CNA 3 stated staff were always told in training that two staff were required when using a mechanical lift to transfer a resident and to call for help all the time. During an interview on 9/14/2020 at 5:45 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was on the floor on 8/31/2020 and that Resident 1 complained of a right hip pain. During an interview, on 9/15/20 at 1:20 p.m., the Director of Staff Development (DSD) stated per facility policy and training two people are required to transfer a resident when using a mechanical lift. During an interview on 10/25/2020 at 3:25 p.m., CNA 3 stated Resident 1 started moving when raising the mechanical lift and complained to CNA 3 that the sling was too tight and hurting her. CNA 3 was asked about mechanical lift safety features five times and did not mention to lock the brakes. CNA 3 stated one staff needs to be in front and the other staff behind the resident when using the mechanical lift to transfer a resident. CNA 3 stated Resident 1 was heavy set, has a large WC, did not have a dedicated sling and staff 555432 11/05/2020 SOLHEIM SENIOR COMMUNITY 2236 Merton Ave Los Angeles, CA 90041 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE use any sling they can find. A review of facility's policy and procedure for Using a Mechanical Lift, dated 2/2019, indicated at least two nursing assistants were needed to safely move a resident with a mechanical lift.