Other·April 10, 2024

§ 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least 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. 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. On 2/26/2024 at 9:15 A.M., an unannounced visit was made to the facility to investigate complaints regarding patient safety. The facility staff failed to ensure that Patient 1, who was assessed as having severely impaired cognition (thought process) and totally dependent to staff for activities of daily living was provided a safe environment and free from accident hazards by failing to prevent injury during transfer from bed to the shower gurney (also called a shower bed, used to transport an immobile person to and from a bathing area) using the mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond manual support), on 2/16/2024. The facility failed to: 1. Ensure Patient 1's bed siderails were down and not left raised (elevated at higher position) while the Patient 1 was being transferred with the mechanical lift from the bed to the shower gurney. 2. Implement Patient 1's mechanical lift care plan (care plan is a systematic and organized document that outlines resident's healthcare needs, goals, and the nursing interventions) by checking the resident's environment for any clutter and environmental hazards that would interfere in the use of the mechanical lift by clearing the area of any obstruction during transfer to avoid Patient 1from bumping or hitting into any hard or sharp surfaces. 3. Ensure Certified Nurse Assistants (CNA) 2 and CNA 3 follow the Mechanical Lift's Manufacturer's Manual indicating not to intermix slings with different manufacturers and to use the approved sling for the mechanical lift. As a result, Patient 1 had a "sudden jerky movement," (a condition which a person makes fast movements that they cannot control and that have no purpose), slipped off the sling while being transferred by the mechanical lift, hit her head on the bed siderail and fell on to the floor. Patient 1 sustained a 2-inch laceration (a deep cut or tear in skin) to the right upper eyelid with bleeding, left and right knee skid (any burn/mark on the skin caused by scraping the skin against a surface), right anterior leg discoloration, right elbow skid, left hip scratch, and edema (swelling caused by too much fluid trapped in the body's tissue) on the right forearm and hand. Patient 1 was transferred to the General Acute Care Hospital (GACH) on 2/16/2024 and returned to the facility on the same night with three sutures to the right upper eyelid. A review of the Admission Record indicated Patient 1, a 40 year old female patient was originally admitted to the facility on 9/28/2012, and readmitted on 3/16/2021, with diagnoses including tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), encephalopathy (a group of conditions that cause brain dysfunction), personal history of traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury), and quadriplegia (paralysis of all four limbs). A review of Patient 1's History and Physical (H&P)" signed and dated by the attending physician on 3/22/2023, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's care plan revised on 12/11/2023, titled ADL (Activities of Daily Living) self-care deficit, indicated Patient 1 required assistance with activities of daily living. The care plan interventions indicated Patient 1 would be provided a safe environment and assistive device for ADLs as needed. A review of Patient 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/21/2023, indicated Patient 1was nonverbal and dependent (helper does all of the effort. Patient 1 does none of the effort to complete the activity) with oral/personal hygiene, toileting hygiene, bathing, upper/lower body dressing, rolling left and right and transfers. The MDS indicated Patient 1's weight was 156 pounds (lbs.-unit of measurement). A review of Patient 1's care plan dated 12/29/2023, indicated Patient 1 required the use of mechanical lift transfer for safety. The care plan interventions included to provide two-person assist during the use of mechanical lift, check environment for any clutter and other environmental hazards that would interfere in the use of the mechanical lift. The care plan interventions also included to clear the area of any obstruction during transfer to avoid Patient 1 from bumping or hitting into any hard or sharp surfaces. A review of Patient 1's Daily Licensed Nurses Note, dated 2/16/2024, indicated Patient 1 required two persons assist with tub/shower transfers. The licensed nurses note also indicated, at 1:05 PM, Patient 1 fell off the mechanical lift. A review of Patient 1's Change of Condition (COC)/Situation, Background, Assessment, Recommendation (SBAR) dated 2/16/2024, indicated at 1 PM, the Patient 1 was being transferred by a mechanical lift to the shower gurney when the Patient 1 had a "sudden jerky movement" and slipped off the sling. The SBAR indicated Patient 1 hit her head on the "bed railing" and hit the floor. The SBAR indicated Patient 11 sustained a "2-inch laceration (a deep cut or tear on skin) to the right upper eye/eyelid noted with bleeding." The SBAR indicated 911 emergency service was called, and paramedics arrived at 1:07 PM. The SBAR indicated, at 1:15 PM, Patient 1was transferred to the GACH by paramedics. A review of Patient 1's Transfer Record, dated 2/16/2024 timed at 1:57 PM, indicated the Patient 1 was transferred to the GACH due to a "Fall/head injury." A review of the GACH, Emergency Department (ED) Summary of Care, dated 2/16/2024, indicated the result of Patient 1's CT (Computed Tomography - diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) Head indicated no acute focal intracranial abnormalities (There is nothing abnormal on the brain scan within the previous 7 days by clinical findings and confirmed by head CT). A review of Patient 1's Change of Condition Licensed Nurses Note dated 2/16/2024 timed at 10:47 PM, indicated Patient 1arrived back to the facility from the GACH around 10 PM, status post (a procedure or event, a patient had experienced or has sustained prior to the current time) fall on 2/16/2024, from the mechanical lift. The licensed note indicated Patient 1 had a 2-inch laceration with 3 sutures (stitches or a row of stitches holding an open wound together) on the right upper eyelid, left and right knee skid, right anterior leg discoloration, right elbow skid, left hip scratch, and edema (swelling) noted on the patient's right forearm and hand. During a review of Patient 1's Interdisciplinary Team (IDT) Narrative, dated 2/21/2024, the IDT Narrative indicated on 2/16/24, at approximately 1 PM, two Certified Nursing Assistants (CNA 2 and 3) were transferring Patient 1via the mechanical lift from the patient's bed to the shower gurney. The IDT Narrative indicated, "In the course of transferring the patient, Patient 1 was slightly elevated from the bed via mechanical lift sling and mechanical lift machine. As the Patient 1had just barely been moved past the edge of the bed, it appeared to the staff that the Patient 1had some sort of full body spasm-like and jerky movement which cause the Patient 1to be propelled out of the head portion of the sling..." The IDT Narrative indicated the CNA (CNA 3) who was guiding the Patient 1was unable to catch or maintain the patient's body. The IDT Narrative indicated Patient 1was transferred to the GACH and returned to the facility approximately 9 hours later. The IDT Narrative indicated Patient 1sustained some swelling to the right arm, right eyebrow laceration, skin abrasions and discolorations on the right elbow and shin. During an observation and interview, on 2/26/2024 at 1:02 PM, Patient 1was observed in the room with eyes open but did not respond to name. Patient 1 was observed with three sutures right below the right eyebrow, three centimeters (cm) in length measured by a 10 cm ruler printed on a 4X4 drain sponge package in Patient 1's room. During an interview on 2/26/2024 at 1:13 PM with Certified Nursing Assistant (CNA) 3, CNA 3 stated that on 2/16/2024, CNA 3 and CNA 2 assisted Patient 1 with transferring the Patient 1 using the mechanical lift. CNA 3 stated they used the "standard size" sling offered by the facility which was the black colored sling (a different manufacturer's lift sling) CNA 3 and CNA 2 used during Patient 1's mechanical lift transfer. CNA 3 stated that CNA 2 was standing behind the mechanical lift, while CNA 3 was maneuvering Patient 1's body inside of the black sling. CNA 3 stated when CNA 2 started pulling the mechanical lift out from over the bed, Patient 1 started to spasm (sudden involuntary muscle contraction [muscle tightening]). CNA 3 stated she was not able to prevent Patient 1 from hitting the right side of the head and falling to the floor. During a concurrent observation and interview on 2/26/2024 at 1:48 PM with CNA 2. CNA 2 identified the mechanical lift used on 2/16/2024 to transfer Patient 1 to the shower gurney. The mechanical lift indicated a warning label indicating to use only product manufacturers' slings and lift accessories. The label further indicated color images of the different sling sizes to be used (Small-Navy, Medium-Purple, Large-Green, Extra Large (XL)-Blue, Extra/Extra Large-Black). During a concurrent observation and interview on 2/26/2024 at 1:53 PM, with CNA 2, CNA 2 identified the black sling that was used on Patient 1while transferring the Patient 1 with the mechanical lift on 2/16/2024. CNA 2 also displayed the label of the black sling indicating a label of a manufacturer's sling different from the mechanical lift's manufacturer used for Patient 1on 2/16/2024 which was not an approved sling. During an interview on 2/26/24 at 2:55 PM with CNA 2, CNA 2 stated while transferring Patient 1 with the mechanical lift on 2/16/2024, Patient 1started to spasm. Patient 1 then started to slip out towards the middle right area of the sling. CNA 2 then stated Patient 1's right shoulder slipped out of the sling then hit the right side of her head onto the left siderail (adjacent to the head of the bed) of the bed and fell to the floor landing on her right side. CNA 2 stated Patient 1's bed siderails were left raised while the Patient 1 was being transferred with the mechanical lift from the bed to the shower gurney. During a concurrent observation and interview on 2/27/2024 at 11:1 AM, with the Director of Staff Development (DSD), the DSD stated the mechanical lift slings the facility uses are one size for every Patient 1and can hold up to 400 lbs. (pounds). The DSD stated the black and the green slings are the same size but did not know if the slings were from the same "company (manufacturer)." The DSD also stated the incident could have been avoidable if CNA 2 and 3 had followed the manufacturer's manual instructions. A review of the facility's policy and procedure (P&P) titled, "Lifting Machine, Using a Mechanical," dated July 2017, indicated "Prepare the environment: Clear an unobstructed path for the lift machine." A review of the Manufacturer's Mechanical Lift Manual dated 2013, indicated that the approved manufacturer's slings and patient lift accessories are specifically designed to be used in conjunction with the manufacturer's mechanical patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of patient lift system. On 2/27/2024 at 4 PM, during a concurrent interview and record review of the Manufacturer's Lift Manual dated 2013, Patient 1's Care Plan for mechanical lift transfer, dated 12/29/2023, and the facility's policy and procedure titled "Lifting Machine, using a Mechanical" dated July 2017, the Director of Nursing (DON) stated that Patient 1's bed siderails should had been put down so the Patient 1did not end up hitting her head on the bed siderail as indicated in the patient's care plan to, "Clear the area of any obstruction during transfer to avoid Patient 1from bumping or hitting into any hard or sharp surfaces." The DON stated the facility staff should always put the siderails down before moving a patient. The DON further stated there is a risk of injury for Patient 1or whoever was using the sling if the CNAs do not use the right sling according to the Manufacturer's Mechanical Lift Manual. During an interview on 3/7/2024 at 9:02 AM, with the Manufacturer's Mechanical Lift's Representative, the representative stated the weight chart to be used by providers to determine the weight of the Patient 1using the Manufacturer's Mechanical Lifts and manufacturer's slings were available on the manufacturer's website. The representative further stated the weight chart for the slings included the following information: -Medium slings can accommodate 100 to 200 pounds (lbs.) -Large slings can accommodate 150 to 300 lbs. and -Extra-large slings can accommodate 200 to 450 lbs. During the same interview, on 3/7/2024 at 9:02 AM, the representative stated, "other company's" slings should not be used because these slings have not been tested with their products. A review of the Manufacturer's Owner's Operator and Maintenance Manual: Patient Slings," dated 12/31/2013, indicated important information for the safe operation and use of the product. The manual indicated a "Warning" indicating "Do not move a person suspended in a sling any distance. The manufacturer's patient lift or the sling are not transport devices. They are intended to transfer an individual from one resting surface to another...otherwise injury or damage may occur." The manual also indicated the manufacturer's slings are made specifically for use with the manufacturer's lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers." The manual indicated to use the manufacturer's approved sling. The facility staff failed to ensure that Patient 1, who was assessed as having severely impaired cognition (thought process) and totally dependent to staff for activities of daily living was provided a safe environment and free from accident hazards by failing to prevent injury during transfer from bed to the shower gurney (also called a shower bed, used to transport an immobile person to and from a bathing area) using the mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond manual support), on 2/16/2024. The facility failed to: 1. Ensure Patient 1's bed siderails were down and not left raised (elevated at higher position) while the Patient 1 was being transferred with the mechanical lift from the bed to the shower gurney. 2. Implement Patient 1's mechanical lift care plan (care plan is a systematic and organized document that outlines patient's healthcare needs, goals, and the nursing interventions) by checking the patient's environment for any clutter and environmental hazards that would interfere in the use of the mechanical lift by clearing the area of any obstruction during transfer to avoid Patient 1from bumping or hitting into any hard or sharp surfaces. 3. Ensure Certified Nurse Assistants (CNA) 2 and CNA 3 follow the Mechanical Lift's Manufacturer's Manual indicating not to inter