cms_AK: 65
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
65 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 689 | D | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure CNA (Certified Nursing Assistant) staff were implementing consistent, safe interventions when conducting Hoyer lift transitions. This deficient practice increased the hazard and risk of falls for one resident (#10), out of 5 residents requiring the use of a mechanical lift, while being transferred from bed to wheelchair. Findings: Record review on 4/23-27/18 of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and required mechanical lift (machine used to move a resident), using 2 staff members for transfers. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #10 was coded as requiring extensive assistance (resident involved in activity, staff provide weight-bearing support) during bed mobility; transfer; toileting; dressing; and personal hygiene. His/her functional limitation to range of motion in lower extremities was coded as impairment to both sides. Resident #11's mobility device was a wheelchair. During an observation on 4/25/18 at 7:46 am, Certified Nursing Assistant (CNA) #1 used Hoyer lift to assist Resident #10 from his/her bed to his/her wheelchair. As Resident #10 was suspended in the Hoyer, CNA #1 placed the wheelchair under Resident #10, tilted the wheelchair back onto its rear wheels and held the wheelchair in that position as Resident #10 was lowered into the wheelchair. During an interview on 4/25/18, CNA #1 stated he/she always tilts the wheelchair back when the resident is lowered from the Hoyer lift. During an interview on 4/25/18 at 2:12 pm, Resident #10 expressed that he/she does not like the wheelchair being tilted back as it makes him/her feel unsafe and unstable. During an interview on 4/27/18 at 9:31 am, CNA #2 stated the wheelchair should be sideways and never tilted, because there is a risk of injury due to tilting. During an interview on 4/27/18 at 2:59 pm, the Chief Nursing Officer (CNO) stated it was not a safe practice to position wheelchair onto its back wheels during Resident lift transfer into wheelchair. Review of Wrangell Medical Center's Policy and Procedures for Mechanical Lift Transfers revealed there is no clear guidance on wheelchair placement/position. Item 11 under Procedures for Bed to Chair reads, Position resident over the wheelchair or chair, first person will guide the resident's legs while the second person is holding resident (in) place using the sling for positioning. | 2020-09-01 |