| 10335 |
MAGNOLIA MANOR METHODIST NSG C |
115004 |
2001 SOUTH LEE STREET |
AMERICUS |
GA |
31709 |
2011-03-21 |
323 |
G |
1 |
0 |
S4HQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received the necessary supervision, and Hoyer lift transfer, as specified by the Care Plan to minimize the risk of a fall for one (1) resident (#1), and failed to use floor mats as specified by the Care Plan to serve as a fall precaution for one (1) resident (#4), from a survey sample of six (6) residents who had been assessed as being at risk for falls. Resident #1 subsequently fell and sustained a fracture of the right leg. Findings include: 1. Clinical record review for Resident #1 revealed a record Face Sheet which documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 02/24/2010 identified the resident to be at risk for falls, with Approaches to address this risk which included to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room by a nursing assistant and observed the resident to be sitting on the floor in the room. This Note documented that the resident had fallen while being changed, and that the resident complained of right knee pain, with swelling noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified of the resident's condition, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that Emergency Medical Services had arrived to transport the resident to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a fracture of the right distal femur. Review of the Corrective Counseling Statement of 02/02/2011, completed as part of the facility's investigative intervention related to this accident involving Resident #1, revealed documentation specifying that this resident was of a no-weight-bearing status, but that the nursing assistant had stood the resident up at the sink to provide incontinence care. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, the Nursing Assistant in-training asked supervisory Nurse "CC" the way of changing the resident, and was told to ask a certified nursing assistant the usual routine. Nursing Assistant "AA" documented that she then asked Certified Nursing Assistant (CNA) "DD" the proper procedure for providing incontinence care to Resident #1, and that CNA "DD" stated the resident could assist and hold herself at the sink with support. Nursing Assistant In Training "AA" further documented that she assisted the resident to the sink, but that during the process of providing incontinence care, the resident let go of the sink and the nursing assistant slid the resident to the floor. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant acknowledged that she had been working by herself when providing care to Resident #1 on the date of the resident's fall. Nursing Assistant In Training "AA" also acknowledged that she had been unsure if Resident #1 was to be changed in bed or assisted to the bathroom for incontinence care. Further record review for Resident #1 revealed that the Care Plan entry of 02/24/2010 addressing the resident's risk for falls also referenced an Approach to use a Hoyer lift for all transfers. The nursing assistant's activities of daily living plan of care for this resident specified the use of a two (2) person Hoyer lift only. In a written statement provided by the Director of Nursing (DON), the DON documented that she had interviewed Nurse "CC", CNA "DD", and also CNA "EE". The DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift. This statement also documented that the resident had fallen and had sustained a fractured leg. The DON further documented that CNA "DD" had admitted that she did not accompany or instruct Nursing Assistant In Training "AA" on how to lift Resident #1, documented that neither CNA "DD" or CNA "EE" were present when the resident fell , and documented that both CNAs had a responsibility to aid and assist Nursing Assistant In Training "AA" while she was in her orientation phase. During an interview with the DON on 03/02/2011 at 2:55 p.m., the DON acknowledged that Nursing Assistant In Training "AA" had attempted to change the resident by standing her up without assistance. The DON also acknowledged that the CNA had transferred the resident without assistance and without using the Hoyer lift, even though the Care Plan specified the use of a Hoyer lift for transfers. Based on the above, the facility failed to ensure that Resident #1, who had [DIAGNOSES REDACTED]. The facility also failed to ensure that the resident was transferred with the use of a Hoyer lift, as specified by the Care Plan. 2. Record review for Resident #4 revealed a 05/19/2010 Care Plan entry identifying the resident's fall potential due to poor endurance, tiring easily and unsteady gait. This Care Plan specified an intervention to place soft floor mats for fall precautions. However, observations of the resident on 03/21/2011 at 3:12 p.m. and 3:35 p.m. revealed that the resident was on the bed, with no floor mats on either side of the bed for fall precautions. |
2014-07-01 |