cms_WV: 11418
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11418 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 520 | E | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility census: 98. Findings include: a) Review of facility abuse / neglect self-reporting to State officials, on 11/11/10 at 9:30 a.m., revealed an incident that took place on 08/15/10 and was reported to the Office of Health Facility Licensure and Certification (OHFLAC, the State survey and certification agency) as an "unusual occurrence". Resident #54 sustained a fracture during an attempted transfer using a sit-to-stand lift. Documentation on the "Immediate Fax Reporting of Allegations" form, in the section headed "Brief description of the incident", stated: "Called to resident's room by staff. Resident holding on to bar of sit to stand (sic) with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor and squad called to take resident to ER (emergency room ) for eval." This form was signed by a registered nurse (RN - Employee #135). - The "Five-day Follow-up" form was completed on 08/18/10 by the facility's social worker (Employee #142). Documentation in the section headed "Outcome / Results of Investigation" stated: "Unusual occurrence - resident slid during attempted transfer. No indication that maltreatment occurred. Resident stated that she let go of handle bar of lift (sit to stand)." There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. - Two (2) written statements were included with the facility's reports from the nursing assistants who had been attempting the transfer. In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." - Review of all documentation associated with the facility's internal investigation found it was unclear how Resident #54 ended up on the floor. Employee #92 stated, "She then let go with the other hand and slid down to the floor." The description by the RN (Employee #135) stated, "Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor ... " There was no evidence of any investigation into statements by staff members of problems with using the sit-to-stand lift when transferring residents into and out of an electric bed, which apparently contributed to the resident's fall. -- b) A review of facility incident / accident reports, on 11/15/10 at 10:30 a.m., revealed an incident report for Resident #54 categorized as a fall, which documented the incident of 08/15/10 at 12:45 p.m. Documentation in the section headed "Describe the circumstances of the event and what actions, if any have been taken currently" stated, "Called to resident's room by staff. Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident was lowered to floor. Unable to move by staff and and squad was called to assist resident. 4 squad members and 2 RN, 1 LPN, 2 CNA (certified nursing assistants) assisted resident on back board and stretcher, support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated 'I am not in w/c (wheelchair) right.' Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor, unable to obtain VS (vital signs) D/T (due to) positioning." Documentation in the section headed "Recommendations to prevent further falls" stated: "Use mechanical lift for transfers." A hand written statement was attached to the report, composed by an RN (#111) and dated 08/16/10. It stated: "(Name of Employee #92), (name of Employee #134), and (name of Employee #81) were re-educated on the sit to stand lift following the (name of Resident #54) fall (sic) RMS (Risk Management System) # 1." There was no apparent investigation of the problem of using a sit-to-stand lift in conjunction with an electric bed. There was no reason given why it was recommended that a mechanical lift should be used with Resident #54 after the fall, instead of the sit-to-stand lift. There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. There was no explanation as to why it was necessary to provide re-education to only these three (3) employees (if nothing had been done improperly); if any re-education were felt to be warranted, there was no explanation as to why this re-education was not then provided to all staff that might use the sit-to-stand lift. -- c) Record review revealed Resident #54 was a [AGE] year old female who was 5' 1" tall and weighed between 280# and 301# during her residency in this facility; at the time of this survey event, Resident #54 resided in another facility. Resident #54 was interviewed via telephone at 9:55 a.m. on 11/16/10. She was asked about the incident of 08/15/10, which she said she recalled clearly. She stated that, when she was being moved in the lift, the lift tipped or lurched, causing her "to go over". She also reported her belief that the lift was broken at the time is was being used. -- d) During an interview with the director of nursing (DON - Employee #88) on 11/16/10 at 11:00 a.m., she stated there were some beds in the facility with which the sit-to-stand lift could not be used. She said the sit-to-stand lift could not be used with the electric beds, because the legs of the lift could not be fully opened when they were under the bed. She demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. -- e) The manufacturer's operating manual for the sit-to-stand lift was reviewed at 10:00 a.m. on 11/16/10. In the section headed "Lifting the patient", was Step F, which stated: "Make sure the legs are in the maximum open position and the shifter handle is locked in place." -- f) An interview was conducted, on 11/16/10 at 10:29 a.m., with the two (2) nursing assistants involved in the above-referenced event (Employees #92 and #134). They both stated that the legs of the sit-to-stand lift were not in the open position when they lifted Resident #54 from the bed and attempted to transfer her to the wheelchair and back. -- g) The facility's administrator (Employee #28), when interviewed on 11/15/10 at 2:30 p.m., was asked if the facility's QAA committee had topics that were always placed on the agenda for discussion by the committee members. He related there were items looked at in every meeting, which included past survey results, customer base, incidents / accidents, abuse / neglect reporting, medication errors, and department-specific topics related to their operations. Discrepancies found by the surveyor during an investigation into the events of 08/15/10, which included a review of written statements obtained by the facility from individual staff members, information obtained by the surveyor through interviews with staff members and a telephone interview with Resident #54, and a review of facility documentation, identified concerns related to the use by staff of the sit-to-stand lift during Resident #54's transfer resulting in a [MEDICAL CONDITION]. These discrepancies were discussed with the administrator, who was asked to provide to the surveyor any additional documentation not previously produced, to demonstrate the circumstances of Resident #54's transfer and fall were reviewed by facility management and/or the QAA committee and steps were taken to ensure no other residents were injured in the future during the use of the sit-to-stand lift. He voiced understanding and stated he had spoken with Resident #54 following the events of 08/15/10, and that she had not said anything to him about the lift tipping or lurching. He stated he had notes of this conversation. He subsequently provided: (1) a "Customer First Ambassador Rounds Worksheet", which he stated was the discussion with the resident when she returned from the hospital; (2) the facility's incident report of 08/15/10; and (3) a policy entitled "Resident / Patient Lifting / Transfer". - Upon review of Resident #54's "Customer First Ambassador Rounds Worksheet", this form consisted of observations and interviews conducted by the social worker (Employee #142) on 08/25/10, 08/26/10, 08/27/10, 09/13/10, 09/15/10, and 09/17/10. The interview questions were general satisfaction items, such as "Was the food appetizing in taste?", "Has the housekeeping staff kept you room to your satisfaction?", "Has the staff been taking good care of you?" The observations were also general in nature, covering areas such as hygiene and grooming, environment, and water pitchers. There was nothing found that addressed the incident of 08/15/10. - Review of the facility incident report provided by the administrator found that additional pages were attached, to include a cover sheet containing the signatures of the administrator and the DON, indicating they had reviewed the investigation of the incident. - Review of the facility's "Resident / Patient Lifting / Transfer" policy found it covered all aspects of lifting and transfer. The only specific mention of the sit-to-stand lift was under Section 4 for "Equipment", which stated: "Sit to-Stand Lifts - designed to assist the caregiver in standing a resident / patient up, without the need for any manual lifting. The resident / patient only needs minimal weight bearing ability to be transferred easily from bed to toilet or chair." There were no specific policies or procedures presented regarding appropriate use and safe operation of the sit-to-stand lift. There was no documented training or education provided to address whether the sit-to-stand lift should not be used with some beds (e.g., electric) or that the legs of the lift must be fully opened before lifting a resident. | 2014-03-01 |