cms_DC: 1715
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1715 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-06-03 | 323 | G | 1 | 0 | HX0R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that inadequate supervision was given to the resident who was improperly transferred and subsequently was found to have a fractured right distal third of the tibia and fibula. The findings include: Resident #1 was born on March 15, 1935 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was assessed as having short and long-term memory problems with severely impaired cognitive skills for daily decision-making in Section C (Cognitive Patterns). Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated April 20, 2013 at 1:06 AM: At 10 PM CNA assigned to the patient called me to come to the patient ' s room to show me the right foot and ankle. He stated that as he/she was doing his/her ADLs he/she noticed a change in (Resident #1 ' s) facial look as he/she was turning him/her. (The CNA) noticed his/her right foot and ankle to be slightly bent. The patient was assessed by (writer) and Nursing Supervisor. The right foot and ankle did slightly bend inside. NP notified and responded with new orders. The right foot is not discolored or swollen upon assessment. Daughter is aware. This is for 4/19/13 at 10 PM. A telephone interview was conducted with Employee #1 on May 2, 2013 at 11:25 AM. Employee #1 was asked about the above concerns and stated, (Resident #1) was sitting in a geri-chair and he/she was making a face like he/she was going to cough. He/she makes that face all the time. That was something normal for him/her. I put him/her back to bed with the Hoyer lift about seven o ' clock (7:00 PM). I had to do it by myself because I couldn ' t find any help. The transfer was okay. Nothing happened during the transfer. I positioned him/her on his/her right side. I put pillows under both legs and between his/her knees and behind his/her back. When I came back about two hours later he/she was grimacing when I touched him/her. I had to find out what happened so I looked at him/her and saw that his/her right foot was bent. I called the charge nurse right away and then I found out that he/she had a broken leg. I know that the Hoyer transfer is supposed to be with two people but I couldn ' t find another person to help me. According to the reports of the x-ray dated April 20, 2013 at 2:56 PM: Spiral fractures distal thirds of tibia and fibula. According to the facility ' s Mechanical Lift , policy no: TX- .05, page one (1) of one (1), effective November 2005: Purpose: To provide a safe transfer of residents/patients by the healthcare provider while operating the equipment in a safe and proper manner at all times . Procedure: 1. The Mechanical lift should be used by at least two (2) care providers at all times with patients/residents who cannot use any other means of transfer . A face-to-face interview was conducted with Employee #2 on April 23, 2013 at 3:30 PM. He/she stated, I don ' t know why (Employee #1) transferred the resident with a Hoyer lift without assistance. That is not our policy. Facility staff failed to properly transfer Resident #1 from the geri-chair to the bed using the Hoyer lift. Resident #1 subsequently sustained a spiral fracture of the distal third of the right tibia and fibula. The record was reviewed April 13, 2013. | 2016-06-01 |