cms_WV: 6291
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6291 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 225 | E | 0 | 1 | ZU6S11 | Based on record review, review of staff training records, employee personnel file review, review of incident documentation, and staff interview, the facility failed to report and investigate an allegation of resident neglect. The resident was improperly lifted with a mechanical lift, resulting in a fall. In addition, the facility failed to ensure a pre-employment statewide criminal background check was completed for one (1) of five (5) newly hired employees. These practices had the potential to affect more than an isolated number of residents. Resident identifier: #30. Employee identifier: #35. Facility census: 105 Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of an incident report, with an incident date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand using the Sara 3000 lift to enable staff to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m. with Employee #159, a nursing assistant (NA). During the interview, she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the resident's mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. During the interview at 1:45 p.m. on 04/09/14, Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. When asked if she had identified the buckles were missing while she was standing Resident #30, she stated she did not notice the buckles were missing from the sling. The NA stated she did not think Employee #33 knew either, because she did not say anything to her while they were attempting to use the Sara 3000 lift. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand the resident. Employee #16 stated the resident complained of pain in her right hip and the physician was notified. She said the resident was transferred to an acute care hospital for evaluation. Employee #16 said the resident returned at a later time that day with a recommendation to follow up with a CAT scan (Computerized Tomography (CT scan)) for her hip and her head. The DCD was asked what had caused the fall. She stated the buckles were cut off the sling so there was nothing to hold the resident in the Sara 3000 lift. The DCD was asked who trained the employees on the use of the Sara lift. She stated training was provided by the company from whom the facility purchased the lifts. The DCD stated upon hire, all nursing staff must watch a video on how to use the different types of lifts in the facility. She stated she did not know when the company may have been in to provide any training on how to use the Sara lift. The NA in-service records were reviewed on 04/09/14 at 2:00 p.m. The Sara lift in-services contained no evidence the NAs were evaluated for competency in the use of a Sara 3000 lift. The in-service records contained only signatures which represented the NAs had watched the videos. An interview was conducted on 04/09/14 at 3:38 p.m., with Employee #64, a registered nurse (RN). When asked how Resident #30 fell from the Sara 3000 lift, she stated the resident slid out of the lift. Employee #64 said an aide told her Resident #30 was lying on the floor. She said when she went to assess the resident, she observed Resident #30 lying on her back with her feet toward the window. The resident's assessment revealed she was having pain in her right hip. Employee #64 stated she called the physician, and the physician told her to send the resident to the emergency room for evaluation. Employee #64 said when her hip was touched, the resident said she was having pain. Employee #64 said she reported the fall to Employee #72, the director of nursing (DON). On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33 and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. The DON said she immediately reviewed, with the NAs, the need to check the integrity of all slings prior to putting them around or underneath a resident. She also said she reviewed the proper use of the Sara lift with the NAs. The DON stated she then took the Sara lift and the altered sling, which was used with Resident #30, to the administrator's office and described the accident and the circumstances surrounding the accident to the administrator. During an interview with the DON on 04/10/14 at 8:30 a.m., she was asked if this incident of neglect was reported and investigated as soon as the facility identified the buckles were missing and the NAs confirmed they used the sling without the required buckles. The DON said they they did not report this incident as required. She confirmed the incident was substantiated for failure to utilize the Sara lift sling appropriately on 04/04/14. b) Employee #35 On 04/09/14 at 11:30 a.m., a review of the personnel files for newly hired employees was conducted with Employee #157, the Director of Human Resources. Review of the personnel file for Employee #35, a social worker who was hired on 03/17/14, revealed no evidence of a statewide criminal background check. The Director of Human Resources verified the personnel file for Employee #35 did not contain evidence of a statewide criminal background check. At 12:30 p.m. on 04/09/14, the Director of Human Resources, provided an appointment slip indicating Employee #35 was scheduled for an appointment to obtain the statewide criminal background check on 03/28/14. She agreed this background check was not obtained prior to employment. | 2018-04-01 |