cms_GA: 18
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 656 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. On 7/18/18 at 12:55 p.m. an interview was conducted with Licensed Practical Nurse (LPN) FF (who was assigned to the resident on 7/5/18) at the D hall nurse's station. LPN FF was asked how does staff know how to care for the residents they are assigned. LPN FF replied, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF was asked to review the ADL sheet and acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. When asked who completed the ADL sheet, LPN FF stated that nursing was responsible for completing at the time of admission, We write it up in pencil, so it can be updated (with information from the care plan). On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked to explain the incident and investigation when R#40 was transferred on 7/5/18 resulting in rib fractures. The DON stated, We had never seen the resident get out of the bed, we want her to get up, but she refuses, and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18 using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know what R#40's transfer status was the DON stated that it was on the ADL sheet (information from the resident's care plan). The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. When asked what the ADL sheet should have documented, the DON stated that it should have been updated to reflect the resident's actual transfer status at that time. The DON further stated that R#40 did not get out of bed and she was totally dependent, and the ADL sheet should have reflected that she needed, at minimum, a two person assist and / or a Hoyer lift for safe transfers. No further information was provided prior to the end of the survey process. Cross reference to F689 | 2020-09-01 |