Other·July 29, 2021

F689: §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. The facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 fell to the floor while being transferred to bed by one Certified Nursing Assistant (CNA) using a mechanical lift. The facility failed to follow their Policy and Procedure (P&P) on requiring two-person assistance with transfers when using a mechanical lift. This failure resulted in Resident 1 being transferred to the acute care hospital due to occipital hematoma (collection of blood) and a left subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Resident 1 required 13 staples to close the skin cut on her scalp. Findings: Review of the facility's P&P titled Mechanical Lift revised 4/2019 showed to verify transfer assistance is needed per Kardex (a way to communicate to the CNAs important information regarding the residents) and obtain additional assistance and needed equipment as indicated. The use of a mechanical lift requires a second caregiver. Review of the facility's P&P titled Lifts and Injury Reducing Devices Manual dated 10/2017 showed the Patient-Care Employees section showing new employees are to be trained on the Lifts and Injury-Reducing Devices Program as part of job-specific orientation and are not to use the lift equipment until they have completed all necessary training and associated skills check-off sheets. Employees will complete and document training during job specific orientation, annually and as required to correct improper use/understanding of safe patient handling movement. Further review of the P&P showed the section for Use of Lifts and Friction Reducing Device showing a subsection Number of Employees Required When Operating a Lift. The P&P showed although one person can operate most models of hydraulic lifts, it is advisable to have two staff members present to stabilize and support the patient. As such, a two-person lift is required when using the lift equipment. Under special circumstances and with proper assessment of the patient, a one-person lift may be acceptable. The location's Interdisciplinary or Care Plan Team must determine and approve the procedure for less than a two-person lift. Medical record review for Resident 1 was initiated on 5/27/21. Resident 1 was admitted to the facility on 3/16/10. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool) dated 4/2/21, showed Resident 1 was cognitively impaired and required two-person physical assistance with transfers. Review of the Therapy Discharge Communication (undated), under the section for Transfers, showed Resident 1 required two-person physical assistance for transfers from bed to wheelchair using a Hoyer Lift (mechanical lift). Review of the Visual/Bedside Kardex Report, under the section for ADLs(activities of daily living)/Restorative care, showed to transfer Resident 1 with two-person assistance using a Maxi-move lift (mechanical lift) and a large sling to the shower gurney for shower/bath as needed. Review of Resident 1's plan of care showed a care plan problem dated 1/9/17, addressing Resident 1's risk for falls related to medical history of CVA (cerebrovascular accident or stroke) with hemiplegia (paralysis on one side of the body), dementia (memory loss and confusion), and dysphagia (difficulty with swallowing). Another care plan dated 3/23/15, was created addressing Resident 1's ADL self-care deficits. The interventions in both care plan problems included to transfer Resident 1 with two persons using the Maxi-move lift with a green or large sling. Review of the Progress Notes dated 5/12/21 at 1653 hours, showed Licensed Vocational Nurse (LVN) 1 was called by CNA 1 at around 1610 hours because Resident 1 fell. The documentation showed LVN 1 found Resident 1 on the floor lying on her back by the right side of the bed. LVN 1 noted "some blood" on the right side of Resident 1's head. The documentation showed CNA 1 was trying to put the resident back to bed after giving her a shower using the mechanical lift. CNA 1 was lowering the resident down and the resident's buttocks were already resting in the bed when the mechanical lift got stuck. CNA 1 tried to reposition the mechanical lift, when the sling came off, and Resident 1 slid off to the floor. The documentation showed the physician was informed and ordered to transfer the resident to the acute care hospital emergency department via paramedics. Review of the acute care hospital's report of the Computed Tomography of the head dated 5/12/21, showed small focus of high left frontal lobe subarachnoid hemorrhage. Review of the acute care hospital's History and Physical examination dated 5/12/21, showed Resident 1 was admitted to the acute care hospital after a fall from the bed about three feet with occipital hematoma and some bleeding. Review of the Progress Note dated 5/15/21 at 2204 hours, showed Resident 1's posterior scalp was observed to have two separated incision sites. Each site was approximately 3 cm with a total of 13 staples. The surrounding skin was observed to be red and boggy from the hematoma. On 5/27/21 at 1020 hours, an interview was conducted with CNA 2. CNA 2 stated she cared for Resident 1 and transferred her sometimes using the mechanical lift. CNA 2 stated the bed needed to be clear, so when she moved the resident with the mechanical lift, the resident's legs would not get caught with the linen on the bed. CNA 2 stated she always needed two persons to transfer the resident: one person controlled the machine and the other person observed to make sure the resident did not get hit on the pole of the mechanical lift. On 5/27/21 at 1027 hours, an interview was conducted with Restorative Nursing Assistant (RNA) Director about the incident. The RNA Director stated Resident 1 was nonverbal with contractures to the bilateral upper and lower extremities. Resident 1 required two-person assistance with bed mobility, cleaning, and transfers. On 6/3/21 at 1437 hours, a telephone interview was conducted with CNA 1. CNA 1 was asked about the incident. CNA 1 stated the incident happened on 5/12/21, at around 1600 hours after she gave a shower to Resident 1. CNA 1 stated she placed Resident 1 on the sling connected to the mechanical lift by herself, moved Resident 1 to the shower room, put Resident 1 on the shower chair, removed the mechanical lift from the sling under Resident 1, and gave Resident 1 a shower. After the shower, CNA 1 stated she connected the sling back to the mechanical lift with Resident 1 sitting on the sling. CNA 1 brought Resident 1 back to the resident's room by herself. CNA 1 stated while she pushed the mechanical lift to place Resident 1 on her bed, the stand of the mechanical lift got stuck with the black cord under the bed. CNA 1 moved the black cord away, and continued to push the mechanical lift. CNA 1 stated at this point, the mechanical lift was jerking. Resident 1 was barely on the bed with her bottoms at the edge of the bed. Resident 1 slipped off from the mechanical lift to the floor, hitting the right side of her head. CNA 1 was asked if she had given Resident 1 a shower before, and if she called for help when transferring the resident using the mechanical lift. CNA 1 stated it was her first time giving Resident 1 a shower, and she did not call for help because everyone was busy. On 6/7/21 at 1707 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was informed Resident 1 fell. When she came to the resident's room, Resident 1 was lying on her right side and her head was bleeding. LVN 1 stated Resident 1 was transferred back from the shower using the mechanical lift by CNA 1. Resident 1 was sitting on the edge of the bed with part of her body on the bed. When CNA 1 pushed the mechanical lift, the mechanical lift got stuck. CNA 1 tried to push, the sling came off from the mechanical lift, and Resident 1 fell on the floor. LVN 1 stated she gave Resident 1 a shower before. LVN 1 stated Resident 1's upper and lower extremities were very contracted, and the resident needed two persons assistance using the mechanical lift. One person helped guide the mechanical lift and another person used the mechanical lift control. LVN 1 was asked if she was trained to use the mechanical lift. LVN 1 stated she could not remember if she was trained before the incident, she knew how to use the mechanical lift because she used to work as a CNA. On 6/21/21 at 1231 hours, a telephone interview was conducted with the Director of Nursing (DON). The DON was asked how the patient care employees (nursing staff) were trained to use the mechanical lift. The DON stated the patient care employees were trained on using the mechanical lift as part of their job orientation. The DON stated the patient care employees had not been trained annually as per their P&P. The above violation either jointly, separately, or in any combination, presented a direct or immediate relationship to patient health, safety, or security.