cms_ID: 71
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 71 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2016-10-21 | 520 | E | 0 | 1 | 224111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of manufacturer's instructions, and record review, it was determined the facility failed to have a Quality Assurance and Assessment (QAA) program that identified resident safety issues requiring the development and implementation of appropriate plans of action to correct the issues. This deficient practice directly impacted 6 of 18 sampled residents (#1, #4, #6, #12, #13, and #14). These deficient practice placed residents at risk of harm due to unsafe mechanical lift transfers and ill-maintained oxygen concentrators, suction machines, call lights, and bath/scale lift. Findings include: 1. Staff were observed unsafely transferring Resident #4 and Resident #6 without following the manufacturer's instructions when using the sit-to-stand mechanical lift. a. Resident #4 was admitted to the facility on [DATE]. Resident #4's MDS assessment, dated 3/4/16, included [DIAGNOSES REDACTED]. The assessment further noted Resident #4 had functional impairment to both sides of his upper and lower limbs. On 10/18/16 at 9:30 am, in Resident #4's room, he was observed during a transfer from his bed to the wheelchair. LN #1 and CNA #5 utilized a sit-to-stand device to perform the transfer. During preparation for the transfer the previously mentioned staff positioned Resident #4 in a seated position on the edge of the bed, while the bed was in a raised position. While they were working with the harness (harness is secured around the resident to assist in supporting the resident), they were discussing how they needed to apply the harness. Resident #4, who later said he was 6 feet and 1 inches tall, abruptly fell backward across the bed. Resident #4 yelled as he fell backward onto the bed. The staff recovered him and returned him to sitting on the edge of the bed. They then assisted Resident #4 to grab the sit-to-stand handgrip, and applied the harness. After securing Resident #4, the staff engaged the lift and transported him to his wheelchair. During the transfer Resident #4 did not stand. He was transferred in a squat like position. An incident investigation, dated 8/7/16, involving Resident #4, documented 2 aides (CNA #6 and CNA #7) were assisting Resident #4 to sit on the edge of the bed to attach the (sling) harness, when he fell backward on the bed. According to the report, Resident #4, at that time, complained of mild ache-like pain between his shoulder blades. The PI (Performance Improvement) Recommendations noted on the incident documented no change to plan of care, CNA re-education. During an interview with the Physical Therapy Director, on 10/18/16 at 2:38 pm, the therapist said the sit-to-stand was still the appropriate method of transfer for Resident #4. She said after the staff told her about the transfer observed at 9:30 am earlier on the same day, she provided training on the correct way to transfer Resident #4. When the surveyor asked if she observed the staff perform the transfer prior to providing the training, she said she had not. The therapist was asked if she was aware of the resident's previous (8/7/16) accident resulting in the same outcome during a transfer. The therapist said she was not aware that this type of accident had occurred before with Resident #4. LN #1 was present during the above transfer of Resident #4 on 10/18/16 at 9:30 am, utilizing the sit-to-stand device. LN #1 did not provide guidance to the CNA related to supporting Resident #4 during the preparation for transfer, appropriate height of the bed, or the inappropriateness of Resident #4's transfer position on the lift. During an interview on 10/19/16 at 6:30 pm, the SDC stated the licensed nursing staff were not required to complete a competency evaluation for the use of the sit-to-stand mechanical lift. The SDC further shared the licensed nursing staff were responsible for signing off the CNAs for the use of the sit-to-stand. b. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/19/16 at 1:17 pm, in Resident #6's room, CNA #3 and CNA #4 were observed transferring Resident #6 to provide incontinence care. Prior to the transfer, Resident #6 was observed sitting in a wheelchair at bedside. The staff placed the sit-to-stand device in front of Resident #6 and proceeded to secure the harness. They instructed Resident #6 to hold onto the handgrips on the device. After securing Resident #6, the sit-to-stand was engaged to lift her from the wheelchair. As she was lifted from the wheelchair, her legs remained bent and she never stood or bore weight on her legs. Her bottom remained at the level of the chair or below as the 2 CNAs provided incontinence care. At one moment during the care, Resident #6 moaned out loud. CNA #4 told her they were almost done with the care and they were hurrying. As Resident #6 dangled from the sit-to-stand, her bottom was at or below the level of the wheelchair she had just been removed from. The harness was up around the upper chest area and her arms were extended up above her chest. After the care was completed, Resident #6 was assisted back to the wheelchair. The manufacturer's handbook for the sit-to-stand, copyright 2014, stated the sit-to-stand device should only be used for residents/patients who can support at least 20% of their body weight. The manual further instructed the facility to assure only trained personnel was permitted to operate the lift. The manual further noted Untrained operators can cause injury or be injured. The manufacturer's instruction were not followed prior to 10/20/16. The SDC was not trained in the use of the device until 10/20/16 and competencies with return demonstrations were not completed for CNAs, nor the LNs, prior to 10/20/16. 2. Untimely and unsafe maintenance issues were identified with oxygen concentrators. Through investigation it was determined that there was no plan for preventative maintenance or servicing of the oxygen concentrators for two residents (Resident #1 and Resident #14) in the sample that were using the oxygen concentrators. a. Resident #1 had a physician's orders [REDACTED]. During an interview on 10/17/16 at 2:30 pm, Resident #1 showed the surveyor his oxygen concentrator. The back of the plastic case showed signs the machine had gotten hot and the plastic was partially melted. Observation of the filter in the machine showed there was buildup of material. Resident #1 stated he had told staff about the problem and that he could not remember when the plastic case melted. The maintenance sticker on the front of the machine showed the last maintenance was 11/13/13 and was due again 11/13/14. The Administrator was informed on 10/17/16 at 4:00 pm, and removed the machine from Resident #1's room. He confirmed he was previously unaware the machine was partially melted and overdue for routine maintenance. b. Resident #14 was admitted to the facility 5/15/15 with [DIAGNOSES REDACTED]. On 10/17/16 at 4:15 pm, Resident #14's O2 concentrator was examined. The filter was in need of cleaning and the last maintenance performed was 9/21/14, and noted maintenance was due to be performed on 9/21/15. Resident #14 stated, at that time, he used the machine every night with his [MEDICAL CONDITION] machine and was not aware of the maintenance issue. The Administrator was notified of the maintenance issues on 10/17/16 at 4:00 pm. At 4:15 pm, the Administrator was observed removing concentrators from oxygen storage room. There were five machines that were removed. Each had different maintenance expiration dates as follows: * Concentrator #1 - Service date: 2/15/15, and service due: 2/15/16 * Concentrator #2 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #3 - Service date: 11/13/13, and due date: 11/13/14 * Concentrator #4 - Service date: 9/21/14, and due date: 9/21/15 * Concentrator #5 - Service date: 11/9/14, due date: 11/9/15 The Administrator was interviewed on 10/17/16 at 4:15 pm, and stated that the facility had a contract with an outside agency to service the machines. On 10/17/16 at 5:20 pm, the maintenance person from the outside agency was in the facility collecting the seven outdated concentrators and replacing them with serviceable ones. The outside agency's maintenance person was interviewed and stated he came to the facility on Mondays and Thursdays to service the liquid oxygen and replace tanks. He was not aware he was to look at, remove, and replace the concentrators for maintenance. The Administrator, District Director of Clinical Services, and Staff Development Coordinator, were interviewed 10/18/16 at 3:00 pm about the failed maintenance on the concentrators and a maintenance schedule. The Administrator indicated there was not currently (10/18/16) a scheduled maintenance plan for the oxygen concentrators in place. 3. Resident #12 who resided in room [ROOM NUMBER], and Resident #13 who resided in room [ROOM NUMBER], shared an adjoining bathroom. During environmental rounds with the Maintenance Director on 10/19/16 at 10:50 am, the emergency call bells for residents who resided in rooms [ROOM NUMBERS] were tested for proper functioning. When the bathroom emergency call bell was pulled for testing, the Maintenance Director immediately reported this call bell has not worked since 10/6/16. The Maintenance Director provided the following information: On the morning of 10/6/16, a CNA presented him with a detached pull cord from the emergency call bell that serviced rooms [ROOM NUMBERS]. It was observed that the call light was not illuminating at the nurses' station or over the door of either resident's room, even when the call bell was pulled manually. On 10/6/16, electric company representatives came to the facility to assess the problem. They were unable to fix the call bell. Cordless doorbells were placed in the residents' bathroom for them to push when they needed assistance while in the bathroom. The doorbells sounded at the nurses' station through a cordless speaker. A TABS (trademark) Alarm was also placed for the 2 residents to use in the event they fell and could not reach the doorbell. Resident #12 resided in room [ROOM NUMBER]. Her MDS assessement, dated 9/15/16, documented she had the ability to express her ideas and the ability to understand others. On 10/19/16 at 10:55 am, she was asked how she would call for help if she were in her bathroom and required assistance. She reported she was mostly independent but would use the call bell in the bathroom. Resident #12 reported she knew nothing of a door bell or that her call bell was non-functional. On 10/20/16 at 10:50 am, the doorbell in the bathroom of room [ROOM NUMBER]/206 was pushed for testing in the presence of the Maintenance Director. During an interview with CNA #1, who was also in the room, CNA #1 reported I do not know what that sound is. I think it means it is time to exercise the residents. The Maintenance Director confirmed facility staff had not received education or in-service regarding the broken emergency call bell in rooms [ROOM NUMBERS], nor had they been educated on the placement of the doorbell, sound of the doorbell, or placement of the TABS alarm. The electric company's report, dated 10/6/16, included a notation indicating the system was old with replacement parts not normally available. On 10/20/16, at approximately noon, the Administrator presented a written document that indicated a cordless doorbell was installed on the left side of the toilet with a speaker placed at the nurses' station to inform nursing staff that help was needed in the bathroom serving rooms [ROOM NUMBERS], due to no visual cue at the nurses' station. On 10/20/16, at approximately noon, the Administrator reported staff would be educated, Resident #13 in room [ROOM NUMBER] was being discharged home, and Resident #12 in room [ROOM NUMBER] would be moved to a room with a functional call bell, and the electric company would make a return visit today (10/20/16) to make another attempt to fix the broken call bell. 4. On 10/18/16 at 8:45 am, a suction machine in Resident #4's room was observed to have a canister attached with approximately 100 cc of clear sputum. The inspection safety test was documented as most recently completed on 2/5/15. The label indicated the next date for the machine to be evaluated was 2/2016. A second suction machine in the room contained an inspection safety test label that documented the last time the machine was evaluated was 2/15/15 and required another inspection to be completed in 2/2016. During the Environmental Tour On 10/18/16 at 10:00 am, with the Maintenance Director, he confirmed not all equipment was checked routinely as required. The Maintenance Director could offer no explanation of the facility's failure to ensure the necessary inspections were completed. Review of the Maintenance Log at this time showed the following items were due for inspection in (MONTH) (YEAR), but were not inspected: * Dining Room Suction Machine * Bath Patient lift/scale * 2 Patient Suction Machines 5. On 10/20/16 at 11:00 am, the Administrator stated there was an annual calendar provided from the corporate office that identified the QA activities to be completed each month. He indicated the facility also used survey deficiencies and the CMS Casper reports for potential QA issues to review. The Administrator said the QA program was doing some quality monitoring, but was unable to explain what that included. The Administrator was unable to explain how the facility's QA process identified issues in the facility that were not listed on the corporate calendar, Casper reports, or survey deficiencies. There was no evidence of the staff identifying and reporting issues to the QA committee for review. The Administrator was questioned about competency of the staff who used the sit-to-stand lifts on residents. He indicated competencies were to be reviewed annually by an outside agency who monitored the facility. The Administrator said the SDC was to report to the QA Committee on the progress of the competencies. The Administer was told the sit-to-stand competencies were not being reviewed, and he confirmed he was not previously aware they were not being done as expected in the facility policy. The Administrator confirmed there was no QA being done to ensure quality care was provided with transfers. The Administrator was asked about the lack of QA involvement by the Maintenance Director, given he was aware of so many safety concerns, and he was not able to explain why the Maintenance Director was not included in the QA process. | 2020-09-01 |