| 10655 |
FOUNTAINVIEW CTR FOR ALZHEIMER |
115697 |
2631 NORTH DRUID HILLS ROAD N E |
ATLANTA |
GA |
30329 |
2010-09-21 |
323 |
G |
|
|
GYV611 |
Based on resident medical record review, staff interview, facility Investigative Report review, and hospital Discharge Summary review, the facility failed to ensure a safe transfer, per facility policy and the plan of care, for one (1) resident (#1) from five (5) sampled residents. This resulted in actual harm to the resident, with the resident sustaining bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and a skin tear on the right hand, with bruising. Findings include: Medical record review for Resident "A" revealed a Care Plan entry dated 05/28/2010 which indicated that resident required the assistance of two (2) persons with total lift transfers. A Nurse's Note of 09/01/2010 timed at 4:00 p.m. documented the nurse had been called to the room of Resident "A" at around 2:35 p.m. by Certified Nursing Assistant (CNA) "CC" and observed the resident with bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and an approximate 2 centimeter (cm.) by 2 cm. skin tear on the right hand, with bruising. This Note documented that the physician was notified, Emergency Medical Services was called, and the resident was transported the to the hospital around 3:00 p.m. A review of hospital Discharge Summary record dated 09/13/2010 for Resident "A" revealed documentation that the resident did not receive fractures and had no orbital damage, but had received sutures to the left forehead. The facility conducted an investigation into this resident's injury and obtained a statement from CNA "CC", who was the CNA who had been caring for the resident during the shift at the time of the discovery of the resident's injury on 09/01/2010. CNA "CC" gave a written statement in which she documented that she and another staff member had put Resident "A" in the bed, changed the resident's diaper, then left the room to assist another resident. The CNA documented that the family of Resident "B", the roommate of Resident "A", then came to her and told her that the resident was bleeding, at which time she returned to the room of Resident "A" and noted the resident to be bleeding and positioned between the rail and the mattress. The CNA documented that she then summoned the nurse. In a documented interview with CNA "CC" conducted on 09/01/2010 by the facility's Administrator and the Director of Nursing, CNA "CC" is documented as stating that she and another staff member, whose name she could not recall, had transferred the resident to the bed using the Vander Lift. In this interview, when specifically asked of the possibility of the resident being hit in the face with the sling assembly of the lift, the CNA indicated that she did not think so. However, in a written statement provided from the family of Resident "B", the roommate of Resident "A", this family member documented that on 09/01/2010 at approximately 2:00 p.m., she had entered the residents' room and observed Resident "A" in the geri-chair, seeming to be "perfectly fine". At approximately 2:15 p.m., the CNA was providing activities of daily living care to Resident "A" in bed with the curtains drawn. Then, at around 3:00 p.m., the family member returned to the room, and noted the CNA coming out of the room. The family member entered the room, at which time she observed Resident "A" laying flat in the bed (rather then being positioned between the rail and the mattress, as claimed in the statement of CNA "CC") and noted bleeding from the head area. The family member then went to summon the CNA to help Resident "A", at which time the CNA came to the room, left to get assistance and then returned with multiple staff members.. The facility's 09/07/2010 Final Report regarding the investigation into the injury involving Resident "A" documented that after interviews which included multiple facility employees, the facility had concluded that the statement given by CNA "CC" had been found to be untruthful. The CNA had indicated in her statement that another staff member had helped during the transfer of Resident "A" with the Vander Lift, that the resident was fine when she left the room to care for another resident, and that the resident was between the mattress and the siderail upon her return to the room. The facility concluded, rather, that based on their investigation, CNA "CC" had failed to follow the facility policy of utilizing two persons for all lift transfers while using the Vander Lift, and that the CNA's statement was untruthful as to the events that occurred. During an interview with the Director of Nursing (DON) conducted on 09/21/2010 at 12:45 p.m., the DON stated that CNA "CC"'s original statement was not true. The DON stated that after interviewing other CNAs who were on duty at the time the resident was injured on 09/01/2010, all stated that they had not assisted CNA "CC" with transferring this resident. The DON stated that two (2) staff persons were to perform this task. Based on the above, CNA "CC" transferred Resident "A" without the assistance of two persons, in violation of facility policy, and the resident was subsequently discovered to have bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and a skin tear on the right hand, with bruising. |
2014-01-01 |