Other·August 2, 2023

REGULATION VIOLATION: 483.25(d) Accidents The facility must ensure that: 483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. 72311(a)(2) 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(a) 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 May 4, 2023, at 2:21 PM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1, a quadriplegic (paralyzed in the arms and legs), who experienced a fall from the facility's Hoyer lift (a mechanical lift used to transfer patients from their bed to a chair, or wheelchair, etc.) on April 20, 2023, when a facility staff member attempted to transfer Patient 1 using the incorrect sling (a harness used to transfer the patient) to move Patient 1 from his bed to his wheelchair. In addition, the facility staff attempted the transfer alone and did not obtain assistance from a second staff member as indicated in Patient 1's care plan (an individualized plan for the medical care of a patient). As a result of the fall, Patient 1 sustained a laceration to the back of his head and required evaluation and treatment at a hospital. Subsequently, Patient 1 was placed on two different kinds of antibiotics to prevent infection, and the laceration required daily wound care for seven days as ordered by a physician. The facility failed to: 1. Provide supervision, monitoring, and support for Patient 1 during a transfer with the facility's mechanical equipment (Hoyer lift). 2. Implement Patient 1's care plan intervention requiring 2-3 staff members to assist with transfers. 3. Implement its policies and procedures to prevent accident hazards and ensure staff operated the facility's equipment in accordance with manufacturer's instructions. Patient 1, a 56-year-old male, was admitted on November 9, 2022, with diagnoses which included quadriplegia (paralysis of the arms and legs), altered mental status, muscle weakness, cachexia (weakness and wasting of the body due to severe chronic illness) and severe protein-calorie malnutrition (inadequate intake of calories from proteins, vitamins, and minerals). A review of Patient 1's care plan titled, "ADL [(activities of daily living)] - care plan," dated January 23, 2023, indicated, "Needs assistance with ADLs: Transfers - Total Assist Support... 2-3 staff assist..." with interventions including, "Assist with transfers, request extra help as needed..." A review of Patient 1's "Minimum Data Set" (MDS - a comprehensive assessment of the patient's functional capabilities) dated March 1, 2023, Section G (functional status) indicated Patient 1 was "total dependence" (totally dependent on staff) for transfers [to and from bed, wheelchair etc.] and bed mobility. The MDS further indicated Patient 1 required the assistance of two staff members during transfers. A review of Patient 1's fall assessment titled, "[name of facility] Fall Risk Evaluation," (a scored assessment of Patient 1's fall risk) dated March 3, 2023, indicated Patient 1 was identified to be at high-risk for falls, with a score of "12." The document further indicated, "...If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls..." A review of Patient 1's "Physical Therapy Recertification and Updated Plan of Treatment" (a summary assessment and plan of treatment for the Patient) signed on April 20, 2023, indicated, "... Patient will safely perform functional transfers with TD [(total dependence)] ... Comments: Hoyer transfers recommended for safety..." A review of Patient 1's physician's orders dated April 20, 2023, indicated the following: "1) Amoxicillin [(an antibiotic used to treat bacterial infections)] 875 mg [(milligrams-a unit of measurements)] - potassium clavulanate [(an antibiotic used to treat bacterial infections)] 125 mg 1 tablet by mouth every 12 hours x [(times)] 7 days...2) Sulfamethoxazole [(an antibiotic used to treat bacterial infections)] 800 mg-trimethoprim [(an antibiotic used to treat bacterial infections)] 160 mg 1 tablet by mouth every 12 hours x 7 days - head laceration/prophylaxis-[(a medication or a treatment designed and used to prevent a disease or illness from occurring)]...3. Back of head laceration treatment cleanse with normal saline wound cleanser, pat dry, cover with dry dressing wrap with kerlix [(a type of gauze dressing)], secure with tape daily & reevaluate in 7 days..." During a concurrent observation and interview on May 4, 2023, at 2:38 PM, with Patient 1, in Patient 1's room, Patient 1 was observed to be unable to move his arms and legs. Patient 1 appeared thin and frail (weak and delicate), and did not verbalize anything when spoken to, but when asked if he fell from a Hoyer Lift recently, Patient 1 nodded his head up and down. During an interview on May 23, 2023, at 2:25 PM, with the Assistant Director of Nursing (ADON), the ADON stated, she was working at the facility on April 20, 2023, at the time when Patient 1 fell from the Hoyer Lift. The ADON stated, she responded to the incident after Patient 1 had fallen to the floor, and because of the fall, Patient 1 sustained a laceration to the rear of his head, which bled and required evaluation at a hospital. The ADON stated, Patient 1 fell from the Hoyer Lift sling, because CNA 1 had used the incorrect sling to transfer Patient 1 with the Hoyer Lift; CNA 1 had used the sling intended to be used with the sit-to-stand lift (a mechanical lift used to aid patients to rise from the seated position but does not support the patient's entire body weight) but should have instead used the full body sling meant to be used with the Hoyer Lift. The ADON further stated, the sit-to-stand sling was not supposed to be used at all with the Hoyer Lift. The ADON stated Patient 1 required the assistance of two staff members when the Hoyer Lift was used, but CNA 1 did not get the assistance of another staff member to assist with the transfer, and instead attempted the transfer by herself. During an interview on May 23, 2023, at 2:44 PM, with CNA 1, CNA 1 stated, on April 20, 2023, she attempted to transfer Patient 1 by herself from their bed to a wheelchair using the Hoyer Lift. CNA 1 stated she was aware Patient 1 required the assistance of two staff during transfers with the Hoyer Lift but stated Patient 1 was not very heavy, so she thought she could attempt to perform the transfer alone. CNA 1 further stated she used the sit-to-stand sling instead of the Hoyer full body sling when she used the Hoyer device to transfer Patient 1, and at the time she performed the transfer, she was not aware that she was using the wrong sling. During a follow up interview on May 23, 2023, at 2:54 PM, with the ADON, the ADON stated two staff members were required to transfer any patient when using the Hoyer Lift, because one person was supposed to stand by the Hoyer Lift while the other staff member was by the patient in the sling, to guide the patient and make sure they did not bump their head or fall. During a concurrent interview and record review, on May 30, 2023, at 4:30 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," undated, was reviewed. The P&P indicated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities... Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents... Individualized, Resident-Centered Approach to Safety... 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: ... d. Ensuring that interventions are implemented..." The DON stated Patient 1 required two staff members during transfers with the Hoyer Lift, but the patient only had the supervision of one staff member at the time the patient fell. A review of the facility's Hoyer Lift [name of manufacturer] operator's manual titled, "Owner's Operator and Maintenance Manual Electric Portable Patient Lift," undated, indicated, "Warning... [name of manufacturer] products are specifically designed and manufactured for use in conjunction with [name of manufacturer] accessories. Accessories designed by other manufacturers have not been tested by [name of manufacturer] and are not recommended for use with [name of manufacturer] products... Operating the Patient Lift... [name of manufacturer] slings and patient lift accessories are specifically designed to be used in conjunction with [name of manufacturer] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [name of manufacturer]'s patient lift system... for the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. Warranty will be voided... Operating the Patient Lift... [name of manufacturer] recommends that two assistants be used for all lifting preparation and transferring to/from procedures... WARNING... DO NOT use slings and patient lifts of different manufacturers... Injury or damage may occur..." A review of the facility's P&P titled, "Policy and Procedure on Hoyer Lift Usage," dated August 2017, indicated, "It is this facility's policy to help move, lift, and transfer heavy residents who are unable to assist, move... 1. Assess physical characteristics of the resident (i.e. weight size, height, age, physical limitations and abilities) and determine if assistance is needed from another caregiver... 5. DO NOT use Hoyer Lift equipment if unfamiliar with procedure... 7. Provide reassurance that precaution will be taken to prevent falls..." A review of the facility's P&P titled, "Policy and Procedure on Fall Prevention and Reduction," dated October 2014, indicated, "Policy. It is this facility's policy to prevent falls to the extent possible and within the control of the facility... 1. Residents, Upon admission, shall be assessed and evaluated for risk for falls or further falls. 2. Residents identified to be at risk for falls or further falls shall have plans of care developed to minimize or reduce risk factors for falls or further falls. 3. Plans of care shall include interventions on the following... Provision of monitoring and supervision to resident to prevent fall incident..." A review of the facility's job description for Certified Nursing Assistant titled, "Certified Nursing Assistant," undated, indicated, "... Purpose of your job position. The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors... Delegation of Authority. As a Certified Nursing Assistant you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties... Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors... Follow established safety precautions in the performance of all duties... Operate all equipment in a safe manner..." In violation of the above cited standards, the facility failed to: 1. Provide supervision, monitoring, and support for Patient 1 during a transfer with the facility's mechanical equipment (Hoyer lift). 2. Implement Patient 1's care plan intervention requiring 2-3 staff members to assist with transfers. 3. Implement its policies and procedures to prevent accident hazards and ensure staff operated the facility's equipment in accordance with manufacturer's instructions. These 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.