cms_GA: 19
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 19 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 689 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively moderately impaired with poor decision making requiring cues/supervision. R#40's functional status was coded as 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. Located in a book at the nurse's station on the unit where R#40 resided there was an undated document titled Nurse Aide's Information Sheet (also referred to by the facility staff as the ADL sheet (a communication tool used by the CNAs to determine a resident's ADL needs, including transfers). Review of the sheet revealed R#40 was documented as requiring assistance of one staff member to place in wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Further review of R#40's clinical record revealed that the resident was discharged from physical therapy on 4/18/18. The discharge summary documented the following; Patient progress and response to treatment: Per Medical Doctor, patient (pt.) is to discharge (D/C) from skilled physical therapy (PT) services. Transfers: Dependent. Review of the Nurse's Monthly Progress Note revealed the following: Dated: 4/24/18, Licensed Practical Nurse (LPN) AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. R#40's Activities of Daily Living are documented as deteriorated. Assistive Devices, Hoyer. Dated: 6/27/18, LPN AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. Assistive Devices, Hoyer. Review of R#40's Nursing notes revealed the following documentation: Dated: 7/5/18 at 3:12 p.m. notified by CNA that resident was complaint of (c/o) severe pain to left side, assessment done, noted resident c/o pain to left rib cage, [MEDICATION NAME] (a pain medication) 5/325 milligrams (mg) tablet (tab), 1 (one) given and Medical Director notified, X-ray of left rib cage and abdominal (ABD) area ordered, son notified. A review of R#40's Patient Report from the mobile imaging company revealed the following documentation: Dated: 7/5/18. Reason: Pain. In: 4:30 p.m. Examination: Left rib series. Findings: The visualized ribs demonstrate fractures of the left lateral 10th and 11th ribs. No underlying pneumothorax demonstrated. No overlying subcutaneous [MEDICAL CONDITION] noted. Patchy infiltrate in the left lung base. Impression: 1. Acute left lateral 10th and 11th rib fractures. 2. Left lower lobe pneumonia. Dated: 7/5/18 at 6:51 p.m. received x-ray report results of abdomen and left rib cage, revealed abdomen with nonobstructive bowel gas pattern and left lateral 10 and 11th rib fractures. Resident denies falling or bumping self into anything, c/o left rib pain [MEDICATION NAME] 5/325 mg by mouth (po) given for pain, spoke with son regarding resident c/o pain to left rib and abdomen area and of x-ray results. Will continue to monitor. Dated: 7/5/18 at 6:55 p.m. X- ray results for abdomen and chest showing fractured left 10th and 11th ribs and left lower lobe pneumonia. Called Medical Director and left message and also faxed results. Awaiting return call at this time. Dated: 7/5/18 at 8:56 p.m. No response from Medical Doctor. 911 called and hospital called and given report to nurse. Son notified that resident was going to be sent to emergency room (ER) for further evaluation. Awaiting transport at this time. A review of R#40's hospital admission record dated 7/5/18, revealed the following documentation: Disposition Summary: Preliminary [DIAGNOSES REDACTED]. Review of the facility investigative report conducted by the Director of Nursing (DON) regarding the incident with R#40 on 7/5/18, revealed the following written statements: Review of the written statement by CNA BB 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. Review of the written statement of dated 7/9/18 revealed a statement from an Occupational Therapist (OT) II who was in the room working with R#40's roommate at the time of R#40's transfer by CNA BB. The OT documented, in part, the following: I observed the CNA complete the transfer without a gait belt as she instructed R#40 to hold her neck as she proceeded to transfer her to the recliner as she held her by the side of her elastic waist pants. At the completion of the transfer I heard R#40 say, I don't want to do that again. The OT was not available for interview during the survey process. On 7/17/18 at 3:30 p.m., an interview was conducted with CNA CC at the D Hall nurse's station. CNA CC was asked what information she was provided regarding each resident's transfer status. CNA CC stated, I am familiar with the residents and know what they need. If I don't know then I will ask the nurse, or I can ask another aide. When asked if there was any type of communication tool, a care card or cheat sheet that directed the aides to the ADL needs of each resident, CNA CC stated I do not know of any. An interview on 7/17/18 at 4:00 p.m., with the Physical Therapy (PT) Supervisor in the therapy office. The PT Supervisor was asked if he was familiar with R#40 and he stated that he had worked with her in (MONTH) and (MONTH) of (YEAR) to get her back to her prior level of function. The PT Supervisor stated that at the request of her family and her physician her therapy was discontinued on 4/18/18. The PT Supervisor also stated at the time of discharge the resident was totally dependent, could not stand, walk or assist with her transfers. She needed a Hoyer lift for transfers. When asked how that information was communicated to nursing staff, the PT Supervisor stated that when therapy documented that someone was dependent nursing knew to initiate a Hoyer lift. An interveiw on 7/18/18 at 9:40 a.m., with CNA DD on the [NAME] hallway. CNA DD was asked how she knew the transfer status of each resident she worked with, especially if they were new to her. CNA DD stated, We have an ADL book that tells us what the resident care needs are. We can go to that book and see what to do. We also meet every day at three o'clock as a team to discuss the residents. On 7/18/18 at 12:55 p.m., an interview was conducted with LPN FF (who was assigned to the resident on 7/5/18 the day of the fall) at the D hall nurse's station. LPN FF was asked, how does staff know how to transfer a resident? LPN FF stated, 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 when asked what she could remember about R#40's functional ability leading up to the 7/5/18 incident, LPN FF stated R#40 could not walk and generally stayed in the bed. She had a recliner and from time to time I would see her in it. When asked how she was normally transferred into the recliner from the bed. LPN FF stated, I would say by a Hoyer lift. The resident had a lot of [MEDICAL CONDITION] and skin issues. I would question her being a one-person transfer, I wouldn't move her by myself and would call for help. LPN FF was asked to review the ADL sheet and the LPN acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. LPN FF commented the sheet was not correct at the time R#40 fell . We write it up in pencil so it can be updated. When asked what should have happened when R#40 was identified as being totally dependent by PT, LPN FF stated that the ADL sheet should have been updated. When asked how an update would be communicated to the aides working with the residents, LPN FF stated, They have to read the ADL book. Further interview with LPN FF revealed that on 7/5/18 the day of the fall, she had administered medications to R#40 at about 9:30 a.m.she was not sure of the time but the aide went in the resident's room to provide ADL care. LPN FF further stated that R #40 was put back into her bed by lunchtime and that she was unaware that R#40 was in pain until she went in to check on her at about 2:30 p.m. at which time she assessed the resident, provided pain medication and contacted the physician. The aide should never have transferred the resident without assistance. LPN FF stated that R#40 was very alert that day, unusually so, and asked to be put in the recliner. She revealed the aide should have asked for help. Before this incident the aides who worked with R#40 had been using the Hoyer lift. On 7/18/18 at 2:30 p.m. an interview was conducted with LPN AA, the Unit Supervisor, at the D Hall nurse's station. When asked about R#40, LPN AA stated that she was very familiar with the resident and that she hadn't been transferred in about two months leading up to the incident as she did not get out of the bed. If she was to be transferred then she was assessed for use of a Hoyer lift as she was not able to turn herself. When asked what it meant when therapy stated someone was total dependent, LPN AA stated that if the therapy department stated someone was total dependent that meant they could not bear weight and would need a Hoyer lift for transfers. When asked about the incident on 7/5/18 when R#40 was transferred, LPN AA stated She wasn't getting out of bed. I don't know what happened, the aide should have used the Hoyer lift. The ADL sheet was reviewed with LPN AA at this time. LPN AA was asked if the information regarding R#40's transfer ability was correct. LPN AA stated the ADL sheet used by the CNAs was incorrect, it documented that R#40 was a one person assist. When asked if this was the document used by the aides to determine a resident's transfer status LPN AA stated that it was. 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 about the incident that occurred on 7/5/18, when an improper transfer occurred with R#40 that resulted in the residents rib fractures. The DON stated, We had never seen the resident get out of the bed. We wanted 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 how to transfer a resident that was new to her. DON stated that it was on the ADL sheet. 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. 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. . On 7/18/18 at 4:30 p.m. an interview with the Administrator and Clinical Services Administrator was conducted in the Clinical Service Administrator's office regarding improper transfer of R#40 on 7/5/18. The Clinical Services Administrator stated that R#40 was transferred improperly and that the ADL sheet should have correctly reflected the resident's transfer status as that was the communication tool used by the CNAs. Observation and interview on 7/19/18 at 12:10 p.m. with CNA GG revealed that R#40 in her bed. During the repositioning observation by CNA GG revealed that she had worked with R#40 for a long time. When asked what R#40 transfer status was between the end of her therapy on 4/18/18 and the date of the incident on 7/5/18, CNA GG stated, When she came out of therapy in (MONTH) she did pretty well, she would stand and pivot but then in (MONTH) she stopped being able to assist with transfers and started requiring a Hoyer lift. CNA GG further stated, Starting then I always used a Hoyer lift on her, she cannot stand. When asked about the ADL book CNA GG stated that she did not realize that the ADL sheet was incorrect and further stated that R#40 had never really been a one person assist, she required extensive assistance regardless of what it says in the ADL sheet. An interview on 7/19/18 at 12:10 p.m., outside of R#40's room , with LPN HH, a nurse who has worked with R#40 consistently since was admitted . When asked about R#40's transfer status and what happened on 7/5/18, the day R#40 fell . LPN HH replied, She has required a Hoyer lift since May. She cannot stand and she cannot walk. Everyone was aware, but the aide was new and had never worked with this resident prior to the date of the incident. The aide should have asked for help or instructions, regardless of what it said on the ADL sheet. CNA BB did not know her. On 7/19/18 at 3:15 p.m. a telephone interview was conducted with R#40's Medical Doctor (MD). The MD was asked to describe R#40's functional status between 4/18/18 and 7/5/18. The MD stated, Zero, she cannot do anything independently, she has to be moved, she cannot do anything. When asked if one person would be able to safely transfer the resident, the MD stated, Absolutely not. That would be unsafe and the resident could not be safely transferred in that manner. She cannot do anything, she has been totally dependent for a long time. A review of the facility undated policy titled Facility Assessment documents, in part, the following: Staff Training Topics: Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. Staff Competencies: Activities of daily living - transfers, using gait belt, using mechanic (sic) lifts. On 7/10/18 the facility submitted a follow up report to the incident that occurred on 7/5/18 with R#40 that documented, Based on written statements and verbal reports, we believe that the left rib fracture happened during resident transfer. No further information was provided prior to the end of the survey process. A post survey telephone interview on 8/1/18 at 1:53 p.m., during Quality Assurance review, with the DON revealed the facility does have a process for what to do if the resident's physician does not return their phone calls. She revealed that the nurse would contact the Medical Director for direction but that the resident was also complaining of shortness of breath and the nurses felt the resident needed to be transferred to the emergency room (ER) for further evaluation. A post survey QA telephone call on 8/2/18 at 10:47 a.m. with the Clinical Services Administrator revealed that the resident had been a resident at the facility off and on for many years and the staff were familiar with her. She stated that the resident had experienced many fractures over the years due to osteopenia. She further revealed that this resident had been refusing to get out of bed for the last two months but that on 7/5/18 had asked to get up. The CNA was a new PRN (as needed) who did not know the resident. She confirmed that the resident was transferred improperly to get out of bed and that the CNA had also transferred her back to bed around lunchtime. It was at this time that the resident began complaining of pain in the rib area which progressed to also having shortness of breath. The Clinical Services Administrator revealed that the nurse did not document the resident's shortness of breath in the nurses notes, although it is documented in the five day report submitted to the state agency. After receiving the x-ray results, the nurse contacted the resident's physician and was awaiting a return call but due to the resident's shortness of breath, the nurse felt the resident should be transferred to the ER for immediate evaluation. The Clinical Services Administrator revealed that neither CNA BB or OT II had reported to nursing the improper transfer on 7/5/18. Review of the, undated, policy titled Physician Notification 5. The license nurse to notified Medical Director if no response from the attending Physician within 4 hours for any medical emergency. Review of an undated policy titled Hoyer Lift Policy: This is the policy to (name of) Facility to use a Hoyer lift as needed to assure a resident is moved safely and as comfortably as possible. Procedure: The procedure for using Hoyer lift includes, but is not limited to the following: There must be at least 2 people to assist with transfer. Review of policy titled Gait Belt Policy and acceptance form revealed that every CNA that works here wears a gait belt. It is your responsibility to wear your Gait Belt daily. The facility provided signed documentation the CNA BB had signed as agreed on 5/8/18, to wear a gait belt. | 2020-09-01 |