cms_WV: 8689
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8689 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 323 | G | 0 | 1 | S35H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility documents, medical record review, and mechanical lift manufacturer representative interview, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents was transferred in a manner to prevent injury. Facility staff utilized a lift pad (sling) not designed for use with the facility's mechanical lift to transfer Resident #77 from a wheelchair to her bed. The resident fell out of the lift pad (sling) while suspended in the air and struck the floor. The resident sustained [REDACTED]. The facility failed to ensure lift pads (slings), not intended for use with their current mechanical lifts, were removed from the facility's inventory. The facility failed to ensure facility staff were adequately trained in the use and operation of mechanical lifts and lift slings. These deficient practices resulted in harm to Resident #77, and placed all residents who required transfers with a mechanical lift at risk of injury. Resident identifier: #77. Facility census: 64. Findings include: a) Resident #77 - Licensed practical nurse (LPN), Employee #15, was interviewed on 04/23/12 at 2:13 p.m. as part of the Stage 1 Quality Indicator Survey (QIS). When asked whether Resident #77 had any falls or fractures in the previous 30 days, Employee #15 stated the resident fell from a mechanical lift on 04/18/12 and sustained a fracture of her left humerus. - Review of facility documents found at 7:30 p.m. on 04/18/12, nursing assistants (NA), Employees #35 and #33 were transferring Resident #77 from the wheelchair to the bed using a mechanical lift. The report documented, Resident in Hoyer lift & (and) fell out. The report documented the resident complained of pain to her left shoulder, left hip, and right foot. - Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/01/12, Section G, found the resident required the total assistance of two (2) or more staff members for transfers. Review of the current care plan with a target date of 05/04/12 found staff were to, Assist resident getting in and out bed using mechanical lift with two staff members. The care plan did not specify what type of lift sling to utilize for this resident. - Further review of the medical record found the resident was transported to an acute care facility following her fall on 04/18/12. She was returned to the facility from the emergency room in the early morning hours of 04/19/12 with [DIAGNOSES REDACTED]. An x-ray report, dated 04/18/12, documented acute fractures of the right third through fifth metatarsal necks (toes). an order for [REDACTED]. On 04/21/12 at 8:00 a.m., a nursing note documented the resident complained of pain to the left shoulder with yellowish discoloration to her left upper extremity, just above the elbow. A physician's orders [REDACTED]. Review of the x-ray results, dated 04/22/12, found the following, .There is a large effusion at the elbow. This is secondary to a nondisplaced supracondylar fracture with very slight posterior angulation. There may be a subtle fracture of the radial head as well . -- An interview was conducted with the director of maintenance, Employee #63 at 9:00 a.m. on 04/25/12. He was asked whether he inspected the mechanical lift following Resident #77 falling from the lift on 04/18/12. Employee #63 stated he attended a meeting concerning the fall and learned the type of sling utilized to transfer the resident was not intended for use with the lifts they currently utilized. He stated the white sling was to be used with a different model of mechanical lift which had been placed out of commission. -- An interview was conducted with the administrator, Employee #55, at 9:00 a.m. on 04/25/12. She stated the white lift pad was removed from use following the resident's fall on 04/18/12. She stated the lift pad had not been removed from inventory when the model of mechanical lift intended for use with the white slings was placed out of commission. -- The staff development nurse, Employee #1 was asked, at 9:00 a.m. on 04/25/12, to provide evidence of NAs #35 and #33 competency related to the use of mechanical lifts. She provided an in-service document dated 03/09/12 on the proper use of the mechanical lift and lift pads (slings). Both NA #35 and #33 were listed. --Employee #1 was asked to demonstrate the use of the different slings and her training methods related to mechanical lifts at 11:15 a.m. on 04/25/12. She stated the NAs watched a video, and then she takes them two-at-a-time and watches them demonstrate lifting individuals using the mechanical lift. She was asked to demonstrate which color and type of lift pad (sling) to utilize for residents of different sizes and different body types. Employee #1 was unable to demonstrate what pads (slings) to utilize in differing situations. She was asked how she taught aides the proper lift pad (sling) to utilize if she could not determine it herself. She stated that she relies heavily on the senior aides. She was asked whether she was aware the facility had a white lift pad present in the building prior to Resident #77's fall. Employee #1 stated she was aware the facility had white lift pads, but had not evaluated the use of this lift pad during the training she provided. -- A NA, Employee #36, was asked at 11:30 a.m. on 04/25/12, about the use of mechanical lift pads. She stated, There are some white ones (slings) from the old lift that we can still use. Employee #1 agreed this information was not accurate. -- Another NA, Employee #47, was asked at 11:45 a.m. on 04/25/12, how aides determined which color and type of sling to use with a mechanical lift. She stated in the presence of the DON that aides use their own judgement when choosing a sling to utilize. -- An interview was conducted, on 04/30/12 at 9:58 a.m., with a representative from the manufacturer of the mechanical lifts currently utilized by the facility. The representative was asked if it was appropriate to utilize a sling from a different manufacturer with the lifts currently utilized by the facility. The representative stated when facilities called and ask that question, they are told no. The manufacturer recommends only use of the slings intended for the model utilized by the facility to ensure safety. | 2016-04-01 |