Health inspection·October 1, 2024

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 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. § 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. On 8/19/24 at 7:30 A.M., an unannounced visit was conducted at the facility for a recertification survey. The facility failed to prevent an accident by attempting to transfer Resident 51 from the bed to wheelchair without the use of a gait belt (a device used to safely transfer a patient with mobility issues). As a result, Resident 51 sustained a fracture to the left humerus (shoulder). In addition, Resident 51's left arm dialysis access site was unusable, requiring Resident 51 to be hospitalized for central line placement to allow for dialysis treatment. During a review of the clinical record for Resident 51, the Radiology Report dated 8/19/24 at 8:24 P.M. indicated, "Acute...fracture of the proximal humeral diaphysis (a broken left upper arm bone...)" A review of Resident 51's Care Plan dated 8/20/24 indicated, "Patient was sent and returned from ER (Emergency Room) with Fiberglass splint and (left arm) placed in a sling..." A review of Resident 51's Progress Note, dated 8/20/24 at 1:30 P.M. indicated "...Dialysis cancelled... resident has severe pain in left arm due to fracture...per MD send resident to hospital for central line placement for dialysis...." A review of Resident 51's Care Plan for at risk for ability to perform ADL's (activities of daily living) dated 3/14/24, indicated, "Resident requires total assistance for sit to stand, requires total assistance with chair to bed to chair transfers...." A review of facility policy titled Gait Belt, Use of revised November 2012 indicated, "...It is the policy that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer. A review of the facility's Policy and Procedure titled Safe Lifting and Moving of Residents revised November 2012 indicated, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents...." A review of the Facility Assessment Tool, dated 6/17/2024 indicated, Core Competencies include "...transfers, using gait belt, using mechanic lifts..." Resident 51 was admitted to the facility on 7/20/20 and readmitted on 9/3/23 with diagnoses including End Stage Renal Disease (a condition in which the kidneys cannot remove waste from the blood), dependence of renal dialysis (a treatment to remove waste products from the blood), and syncope (fainting), according to the facility's Admission Record. On 8/19/24 at 12:20 PM, a concurrent observation and interview was conducted with Resident 51. Resident 51 was in her room, with her lunch tray in front of her. Resident was grimacing and pointing to her left shoulder and stated "pain!" On 8/19/24 at 12:20 PM an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 51 complained of left shoulder pain after being transferred from her bed to wheelchair at approximately 7 A.M. that morning. Resident 51 was assisted by 2 NOC shift CNA's (CNA 2 and CNA 3). CNA 1 stated Resident 51 "...is always a 2-person transfer with a gait belt...." CNA 1 stated the resident was scheduled to have an x-ray of the shoulder. On 8/20/24 at 8:20 A.M., Resident 51 was observed in her room with the left arm wrapped with a brown elastic bandage and placed in a sling. On 8/21/24 at 6:21 A.M., an interview was conducted with CNA 2. CNA 2 stated on 8/19/24, he assisted another CNA (CNA 3) to transfer Resident 51 from the bed to the wheelchair. CNA 2 stated he placed his arm under Resident 51's left arm, while CNA 3 placed her arm under Resident 51's right arm. CNA 2 stated he and CNA 3 lifted Resident 51 from the bed lifting Resident 51 up by placing their arms under the resident's armpits. CNA 2 stated after lifting Resident 51 from the bed, she began to slip down. CNA 2 stated he grabbed Resident 51's hand and heard a "pop." CNA 2 stated a gait belt was not used to transfer Resident 51. 08/21/24 09:06 AM an interview was conducted with Physical Therapist (PT) 1. PT 1 stated Resident 51 required a 2-person, total assistance with transfers. PT 1 stated residents who required total assistance needed a gait belt during transfers. PT 1 stated during transfers, staff should have their hands on the gait belt, not under the resident's arms. PT 1 stated Resident 51 was at risk of injury if staff used Resident 51's arms for control during transfer, place of a gait belt. On 8/22/24 at 3:47 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff should have used a gait belt while transferring Resident 51. The DON stated a safe transfer for Resident 51 meant two-person assist with a gait belt. The DON acknowledged by not using a gait belt, Resident 51 was not safely transferred from bed to chair. In violation of the above cited standards, the facility failed to prevent an accident by attempting to transfer Resident 51 from the bed to wheelchair without the use of a gait belt (a device used to safely transfer a patient with mobility issues). As a result, Resident 51 sustained a fracture to the left humerus (shoulder). In addition, Resident 51's left arm dialysis access site was unusable, requiring Resident 51 to be hospitalized for central line placement to allow for dialysis treatment.