Health inspection·January 7, 2022

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. § 72311 (e) Any untoward response or reaction by a patient to a medication or treatment. On 10/22/2021 at 1:20 p.m., an unannounced visit was conducted at the facility to investigate a complaint of a fall with injury. The facility failed to: 1. Ensure staff detached the fourth hook from the sling of a mechanical lift, while transferring Resident 1 to bed. 2. Provide training to all staff, including Certified Nurse Assistant (CNA 3) on how to detach and unhook the sling for a mechanical lift during transfer. These failures resulted in Resident 1 falling onto the floor, hitting his head, sustaining a forehead laceration and two vertebral (back) fractures. During a review of Resident 1's admission record Resident 1 was admitted to the facility on November 11, 2019, and was readmitted on October 12, 2021, with diagnoses that included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), sepsis (a life-threatening complication of an infection) and hypertension (high blood pressure). During a review of Resident 1's "Care Plan", dated April 16, 2020, and reevaluated on August 2021, Resident 1 required assistance, was dependent in transfers and had a history of falls. The Care Plan indicated the facility will use a mechanical lift for transfers which required two-person physical assistance. The listed interventions included to: 1. Follow guidelines for safety with mechanical lift transfers. 2. Proper staff training with mechanical lift transfers. 3. Observe safety at all times. During a review of Resident 1's History and Physical (H&P) dated August 11, 2021, the H&P indicated Resident 1 was alert, oriented to person and place, and was moderately demented (affected by dementia) {a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities} with slow mentation (slow mental processing). During a review of Resident 1's "Minimum Data Set" (MDS-comprehensive screening tool), dated August 13, 2021, the MDS indicated Resident 1 usually made himself understood, sometimes understood others and was totally dependent on staff for transferring, toileting, and personal hygiene. During a review of Resident 1's Change of Condition SBAR {(situation, background, assessment and recommendation) a tool to aid in facilitating and effective communication between nurses and providers} - Actual or Suspected Fall note dated, October 11, 2021 the SBAR indicated Resident 1 had a witnessed fall with injury, involving the use of a mechanical lift. The narrative portion of the report indicated Resident 1 was being transferred with two CNA's using a mechanical lift, the sling remained partially attached to the lift causing Resident 1 to be dragged or rolled off the bed onto the floor and sustaining an approximate seven-centimeter (unit of measurement) laceration on the right side of his forehead that was actively bleeding. During a review of the Physician Orders dated October 11, 2021, the physician ordered to transfer Resident 1 to the General Acute Care Hospital (GACH) for evaluation post fall with injury to right side of forehead. During a review of the Emergency Department (ED) notes from the General Acute Care Center (GACH) dated October 11, 2021, the ED note indicated Resident 1 was brought into the ED by the paramedics after sustaining a fall and right-side head laceration at the facility while being transferred with an assistive device. Part of the device failed dropping Resident 1 approximately five feet to the ground. Resident 1 was monitored in the ED for 24 hours and was noted to be alert, nonverbal, and withdrew to pain. Resident 1 was given intravenous (administered through the vein) antibiotics, intravenous pain medication, and underwent several imaging studies. While in the ED the laceration to resident 1 right forehead was repaired with surgical glue. Resident 1 was diagnosed with having two acute vertebral fractures while in the ED that did not require surgical intervention. During a review of the ED Computed Tomography (CT) scan (medical imaging technique used to get detailed images) of the abdomen (tummy) and pelvis (located between the abdomen and the legs) dated October 11,2021, the CT scan results revealed Resident 1 had acute vertebral fractures of the Lumbar (L) Spine (lower back) and Thoracic (T) spine (runs from the base of the neck to the bottom of your rib cage) L1, T1, and T5 acute fractures. During a review of the ED CT Cervical Spine scan (neck) dated October 11, 2021, there was a T1 vertebral body compression fracture that was very likely acute (of short duration) or subacute (between acute and chronic [a conditions that last 1 year or more]. During an observation on October 22, 2021, at 1:40 p.m., in room 24, Resident 1 was lying in a low-profile bed with no side rails. Resident 1 was not responsive to the surveyor's greeting and appeared to be sleep with his eyes closed. There were four mechanical lifts stored outside the building, just beyond the south-west patio entrance (about 10 feet from room 24). During an interview on October 22, 2021, at 2:40 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on October 11, 2021 around 8 a.m., she was called to room 24 by a Certified Nursing Assistant (CNA) to check Resident 1. When she entered the room, the DON was present. LVN 1 stated the resident was on the floor laying on his left side and was bleeding from his forehead. LVN 1 stated she was informed CNA 2 and 3 were transferring Resident 1 to his bed using the mechanical lift. They unhooked three of the four sling hooks and one hook remained attached to the mechanical lift. When CNA 2 and CNA 3 tried to remove the mechanical lift, Resident 1 was dragged onto the floor and hit his head on the base of the mechanical lift. LVN 1 stated pressure was applied to the resident's forehead, 911 was called, and the doctor was notified. During an interview on October 22, 2021, at 3:05 p.m., with Maintenance Supervisor (MTSUP) MTSUP stated the mechanical lifts are inspected monthly. Maintenance staff check the wheels, motor, and check for loose screws and bolts. The mechanical lifts were working properly and are tagged every month after the lifts are checked. If staff report issues with the mechanical lifts, he removes the item, so it is not used for patient care. During an interview on November 29, 2021, at 11:54 a.m., with CNA2, CNA2 stated during a two-person transfer using the mechanical lift CNA2 and 3 forgot to remove the fourth hook from the lift which caused Resident to fall onto the floor hitting his head. CNA2 stated it was an accident and she knew she should have unhooked all four hooks from the lift. During an interview on November 30, 2021, at 2:20 p.m., with CNA3, CNA3 stated she was helping her coworker CNA2 transfer the resident using the mechanical lift and CNA2 and 3 forgot to remove one of the hooks causing the resident to fall onto the floor and hitting his head. During a review of the undated Preventative Maintenance Monthly Log, the mechanical lifts had been checked monthly from November 2019 thru September 2021, and indicated that the four mechanical lifts were okay, and checked, as evidenced by a check mark for all months in 2020 and 2021. During a review Resident 1's licensed nurse discharge progress note, dated October 11, 2021, Resident 1 was transferred to the GACH for a fall with injury (laceration on the right side of his forehead). During a review of the CNA2's "Orientation Competency Evaluation" and "Mechanical Lift Competency Checklist" both dated, September 2021, indicated CNA 2 was checked off as being competent in the use of a mechanical lift. During a review of the CNA3's "Orientation Competency Evaluation" dated, February 27, 2020, indicated CNA3 was not evaluated for the use of a mechanical lift upon hiring. During a review of the CNA3's "Mechanical Lift Competency Checklist" dated, September 15, 2021, indicated CNA3 was checked off as being competent in all areas of the mechanical lift except unhooking the sling. During an interview on December 1, 2021 at 9:48 a.m., with the Director of Nursing (DON), DON stated he was one of the first responders to room 24 after Resident 1 fell from the mechanical lift. CNA2 and CNA3 were transferring Resident 1 using the mechanical lift and CNA2 and 3 forgot to unhook the sling from the mechanical lift causing the resident to fall onto the floor. Resident 1 was transferred via paramedic to the ED for evaluation due to the head injury. DON stated he ensured staff was properly trained on how to use the mechanical lift. DON also stated he believed the accident was avoidable. During a review of the facilities undated "policy and procedure" (P&P) titled "Using a Mechanical Lifting Machine", indicated staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The P&P also indicated when the transfer destination is reached, the resident should be slowly lowered to the receiving surface and the staff should detach the sling from the lift. The facility failed to: 1. Ensure staff detached the fourth hook from the sling of a mechanical lift, while transferring Resident 1 to bed. 2. Provide training to all staff, including Certified Nurse Assistant (CNA 3) on how to detach and unhook the sling for a mechanical lift during transfer. These failures resulted in Resident 1 falling onto the floor, hitting his head, sustaining a forehead laceration and two vertebral (back) fractures. These violations had direct or immediate relationship to the health, safety or security of patients or residents.