| 41 |
WILLOWBROOKE COURT AT COUNTRY HOUSE |
85003 |
4830 KENNETT PIKE |
WILMINGTON |
DE |
19807 |
2019-04-15 |
689 |
D |
1 |
0 |
0KN111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, review of facility and other documents as indicated, it was determined that the facility failed to provide 2 person/staff physical assistance for one (R1) out of three (3) sampled residents. R1 was totally dependent for 2 person/staff physical assistance for transfers to and from the bed, chair, wheelchair and into a standing position. R1 was transported to the bathroom via standup lift with one staff member and the standup lift ran into the bathroom door jam. R1 hit his/her left elbow on the door jam and was noted to have a 1.5 x 3.0 cm. bruise (area dark purple) on the elbow. The facility failed to ensure that R1 was provided 2 person/staff physical assistance with transfers when they used a standup lift with one person to transport R1 to the bathroom, which was not in accordance with the resident's assessments and plan of care to prevent accidents. Findings include: The facility's undated Policy and Procedure entitled, Lifting/Transferring/Repositioning Resident Safely stated, .3. Lifting/Tranferring/Repositioning when a mechanical lift device is indicated: .b. Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance . Review of R1's clinical record revealed the following: 8/16/17- R1 was admitted to the facility. R1's [DIAGNOSES REDACTED]. 8/17/17 - (last review date 3/21/19) A care plan was initiated entitled, ADL self-care performance deficit r/t Disease process, weakness, impaired balance. Interventions included, Transfer: require extensive assistance by (2) staff to move between surfaces other than toilet; now require the standup lift also as recommended by PT. 12/11/18- R1 was referred to OT for therapy due to complaints of increased pain, decreased range of motion in bilateral shoulder function, and difficulty reaching the grab bar to transfer to the toilet. Per OT's assessment, R1's plan of care was impacted by obesity, difficulty walking, inability to stand upright, and depression. OT's initial assessment indicated maximum assistance of 2 persons for functional transfers from wheelchair to bed. 12/11/18- A care plan entitled, skin tears RLE r/t suspect bumped leg was initiated. The interventions included: Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. 12/12/18- R1 was referred to PT for decline in functional mobility and increasing generalized weakness. R1 required maximum assistance with transfers from a sitting to a standing position. 12/12/18 - R1's quarterly MDS Assessment stated that this resident's BIMS score for mental status was 15 (decisions consistent/reasonable). Functional Status: bed mobility-extensive assist/2 person physical assist; non-ambulatory (uses motorized wheelchair for mobility), and transfer-extensive assist/2 person physical assist. 1/3/19- An incident report for R1 stated that the resident reported on day shift that a CNA was in a bad mood and roughed her up. R1 clarified that roughed up meant that the CNA had R1 in the standup lift and ran the lift into the door jam (on way to the bathroom) and resident hit his/her arm on the door jam. 1/4/19 9:52 AM- A nursing progress note stated that a 1.5 x 3.0 cm bruise was noted on R1's left elbow and the area was dark purple and the skin was intact. R1 denied pain when the area was touched. 4/11/19 2:30 PM- E3 (ADON) revealed during an interview that on 12/18/18, as per PT's recommendation, R1 needed 1 person assist with transfers, however, on 12/24/18, PT recommended that R1 needed extensive assistance with 2 person physical assist for transfers as coded on 12/12/18 and 3/6/19 MDS quarterly assessments. 4/15/19 1:50 PM- An interview with E5 (CNA) who took care of R1 today (4/15/19), confirmed that R1 currently had 2 staff physical assistance with the standup lift. E5 also stated that 2 person staff assist had been in place for awhile. The facility failed to ensure that R1 received 2 person/ staff assistance during a transfer using the standup lift on 1/3/19, according to the facility's plan of care to ensure the safety of R1 from accidents and injury. This deficient practice resulted in potential for harm when R1 sustained a bruise on his/her left elbow. Findings were reviewed and confirmed with E1 (NHA) and E2 (DON) at 2:15 PM on 4/15/19. |
2020-09-01 |